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Child & Family Psychology Center • Dr. Margo Napoletano, PhD, Director
New Patient Form: Policies & Consent to Treatment

New Patient Form:  Policies & Consent for Treatment for offices of Dr. Napoletano

Patient Name_____________________________________Birthdate__________Age_______
Address_________________________________________City______________Zip________
Phone_______________________Work phone_________________Marital Status__________
SS# of policy holder______________________Driver’s Lic.#__________________________
Employer or school________________________________Referred by___________________
Insurance________________________Name on Card_________________________________
Insurance ID#_______________________Group#__________________Date effective______
Other insurance?______________________________________________________________

Welcome to our offices.  Our goal is to provide you with the best possible and highest quality professional, psychological services.  First, there is some important information you must have.

The therapy relationship is a professional and confidential one.  What is discussed in the session is generally protected by professional and ethical standards.  With a few exceptions, all material that you disclose is confidential and cannot be released without your written consent, except where disclosure is required by law.  Disclosure may be required in the following cases:  reasonable suspicion of child or elder abuse, reasonable suspicion that a patient is a danger to self or others, and in certain legal proceedings, such as a subpoena.

The first appointment will focus on the problems/concerns which motivated you to seek a consultation with a psychologist.  On the basis of this session, treatment options will be discussed.  If we cannot help you, every effort will be made to refer you to the proper professional/agency to best meet your needs.  Sessions are 45 minutes long, reserved only for you.  Except in cases of emergencies, there will be a charge for missed/cancelled sessions unless you call within 24 hours of the appointment.

Parents of minors have a legal right to information and to give consent for treatment, unless otherwise stated by law.  However, minors have the right to a confidential relationship and these confidences will be respected, as deemed appropriate by the psychologist.  NOTE: parents/caregivers must supervise children at all times; unsupervised children cannot be left in the waiting room.  Our insurance is not responsible for unsupervised children.

Financial agreement:  Fees for services are to be paid at the time of service.  If you use insurance, our office will bill your insurance if benefits are verified/authorized.  The undersigned agrees to authorize insurance benefits directly to Dr. Napoletano.  The fee for the first diagnostic consultation is $225; each traditional “talking” session is $175 per 45 min. session.  Fees for other services will be quoted before they are rendered (e.g., testing, clinical hypnosis, EMDR, biofeedback/neurofeedback).  The undersigned is responsible for fees regardless of insurance coverage, including a fee for cancelled/missed appointments with less than 24 hrs notice.  Unpaid bills are sent to Collection.  The undersigned has read and understands the above information and acknowledges receipt of the HIPAA Privacy Practices Notice (download “Forms” from www.childandfamilycenter.com or obtain at office). A copy of this signature is as valid as the original.

_____________________ _____________________ ________
Patient Name Printed Patient Signature Date
 
A Copy of this signature is as valid as the original.