FORMS

Please fill out and submit the following three forms in order to request an appointment.

Consent Form

Carrie Sandman, LMHC, ATR

Consent for Treatment

I am requesting mental health services for myself and/or my family members. Person(s) to receive services:

First name

Last name

Please list all family members who will be participating in mental health services:

I understand that services may include psychiatric or psychological assessments, individual, group, art or family psychotherapy, psycho-educational services, and/or consultation.

I understand that all forms of mental health treatment in which I participate are to be performed at my own risk and without liability to the independently licensed service provider, Carrie Sandman, ATR, LMHC or the Landlord. Initial consultations are scheduled for one hour; all other sessions are forty-five (45) minutes unless otherwise agreed upon by the provider.

I understand that all information shared with my service provider will remain confidential in accordance with federal and state regulations. I understand that any information about my treatment will not be released without my written authorization, unless as otherwise specifically provided by law. I understand that records of my treatment are subject to review by the third party payer, if applicable.

Appointment times will be arranged for the mutual convenience of the client and the service provider. If I am unable to keep a scheduled appointment, I agree to call and cancel within twenty-four (24) hours, or the prior business day, in advance of the appointment. I understand that I am responsible to pay for appointments that I do not cancel within twenty-four (24) hours. A cancellation fee of $75.00 will be charged for “no-show” or appointments cancelled in less than 24 hours. All fees or fee arrangements are due at the time of service.

I acknowledge that Carrie Sandman, ATR, LMHC is being hired to provide psychotherapy services, and not to be involved in legal/forensic proceedings. Should Carrie Sandman, ATR, LMHC be subpoenaed for clinical testimony, an hourly rate of $200.00 will be paid by the client.

I will retain a copy of this signed agreement for my records. By signing this instrument, I acknowledge all obligations contained herein.

Client Signature

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Parent Signature (if client is a minor)

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Witness Signature

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Thanks for submitting!

Carrie Sandman, LMHC, ATR

91 Main St. Suite 130

Warren, Rhode Island 02885

401-999-0534

1.Important Insurance Policy Information

2.Responsibility for Payment for Service

3.HIPAA agreement

PLEASE CONTACT YOUR HEALTH INSURANCE CARRIER TO UNDERSTAND AND KEEP TRACK OF YOUR BENEFITS.

REJECTED CLAIMS

I agree that if claims for services rendered are rejected by my Health Insurance due to changes in my insurance, that I will pay for the session in full. As a client of Carrie Sandman ATR, LMHC, I accept responsibility for any/all co-payments, co-insurance and or deductibles that apply at the time of service. I understand that Carrie Sandman, ATR, LMHC will submit claims to my insurance carrier for payments for services rendered and that it is not a guarantee of payment.

OUT OF POCKET EXPENSES AND DEDUCTIBLES

Carrie Sandman, ATR, LMHC is not responsible for tracking Out of Pocket deductibles and/or Out of Pocket co-payments that may apply to your individual Health Insurance Policy. Please let us know as soon as possible when you have reached your Maximum Out of Pocket expenses and your deductible so that we can make the correct adjustments and reflect it in our system.

CANCELLATIONS/MISSED APPOINTMENT FEE

I require 24 hour prior notification for cancellations. You will be charged a fee from $75.00. Exceptions are made due to illness or emergency.

HIPAA

I have been given a copy of the HIPAA policies regarding Privacy and Sharing of my personal Medical Information.

By signing this document, I agree to the terms and policies written above.

Client Signature

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Print Name

Thanks for submitting!