Prior to your initial consultation appointment, there are several forms that must be completed and returned to me. This information will help provide me with important information and an overview of any areas of concern that you or others may have.

Intake Forms

All new clients should complete the Patient Registration Form and Health Questionnaire. After doing so please download hard copies of the Summary of Agreement, Maryland Notice Form and Psychologist-Patient Agreement.  You will want to read and understand these forms and bring a signed copy of the Summary of Agreement form with you to your initial appointment.

If you prefer to download and complete hard copies of all of these forms click here.

Records from Other Providers

If you are, or have been treated by a psychologist, social worker, employee assistance program, psychiatrist, neurologist or any other health care professional, it would be very helpful to have your records forwarded to me during the course of our work together. You will need to complete and sign an Authorization for Release of Medical Records so that your other health care providers and I can speak with each other and/or share limited medical records to coordinate your care.

Please download the Authorization for Release of Medical Records form here.

Insurance Information

You will want to call your insurance company if you intend to use your health insurance to cover my fees. Presently, I only accept EHP insurance and fee-for-service/self-payment. If you have insurance coverage other than EHP, you will need to inquire about your out-of-network benefits; in such cases, I will be happy to provide you a receipt for payment that you can submit to your insurance company for reimbursement.

When you call your insurance company, be sure to ask the following questions:

• Is pre-certification or pre-authorization required? Write down the authorization number or code.
• How many sessions will the insurance company authorize before a treatment plan is required?
• What are the "reasonable and customary" amounts covered for the initial intake session (CPT code 90801) and for follow-up sessions (usually CPT code 90806) provided by a psychologist?
• Do you have a deductible you need to meet before your insurance starts to cover payment? If so, how much of the deductible do you still have to meet?
• How much is your co-pay?
• Is there a maximum number of sessions per calendar year, and is there a lifetime maximum number of sessions? If so, how many of these sessions have been used?

On-Line Payment Option

To make secure on-line payments using Google Checkout click here.

Additional Information

My fee schedule is detailed in the Psychologist-Patient Service Agreement, one of the forms in the New Patient Packet. If it is necessary to cancel your appointment, please do so at least 48 hours prior to the date of the scheduled appointment. Failure to cancel your appointment with sufficient notice will result in a cancellation fee for which you will be responsible and will not be reimbursed by your insurance company.

For directions to the office click here. Please note that if you plan to arrive for your appointment prior to 7:30 a.m. or after 5:30 p.m., you may need an access code to the front door of the office building. Please be sure to request this from me in advance.

Do not hesitate to email or call me if you have any questions or concerns. My emergency contact information is available on my voicemail.

To open the forms above, you will need Adobe Reader.