Location:
28 South Pitt Street
Carlisle, PA 17013
phone: 717-713-0059
Appointments are available on:
Tuesdays and Thursdays 3-8pm starting Jan 3, 2012.
Your first appointment:
Please fill out the following forms and bring them with you to your first appointment. If you are unable to download/complete these forms, please come 20 minutes prior to your appointment and the forms will be provided for you in the waiting room.
For adult clients 18 and older:
For parents of adolescents ages 13-17:
For parents of children 12 and under:
Optional/Miscellaneous forms:
This form contains information about your privacy rights under HIPPA. Please read this form and keep it for your records. You do not need to bring it to your appointment.
Please print and fill out this form if you would like me to share information about your treatment with another person (your primary care physician, a child's teacher).
Please print and fill out this form if you would like to pay for your treatment (including co-pays and deductibles) by credit card.
Fees:
Insurance: I am currently in-network with Aetna, Highmark Blue Shield, Capitol Blue Cross, MHNet PPO (Health America), and Value Options. If I do not participate with your insurance plan, I may be able to see you as an out-of-network provider, provided you have these benefits.
I have a no-hassle insurance policy. I will call your insurance company for you and let you know exactly what is covered and what is not. I will arrange for any necessary authorizations, and bill your insurance directly for your care if I am in-network. I will take care of the details so that you can focus on feeling better.
Private Pay: If you do not have insurance benefits, please call for current session rates. Payment for
services is required at the time of each session. Credit cards accepted.
A payment form will
open in
a new window. Enter the name of the client in the first box. Enter my License Number 017855 in the second box labeled "License or Tax ID number of Recipient of Payment." Complete
the form and click on the Submit Payment button at
the bottom. Print
yourself a copy of the receipt that will appear on screen.
