Client Info & Release Forms
The following PDF files are for your convenience as a patient. Please take time prior to your initial session to read and complete the following forms. It will expedite office time and simplify your experience at San Tan Counseling.
All forms are in PDF format and require a compatible reader.
» Client Information Form (required)
» Personal History & Treatment Form (required)
» New Patient Assessment Form (ages 5-17)
» Consent for Treatment of a Minor
» Authorization to Release or Request Personal and Confidential Information
» Tele Therapy Consent (COVID-19 Therapy Sessions)
Brochures & Useful Information
NEW PATIENT INFORMATION
It is important that you come prepared for each patient visit.
No children unattended.
Electronic devices on silent.
No food or drink.
Take phone conversations outside.
Be courteous of others in the waiting room.
Clean up after yourselves.
Contracted with most insurance plans with mental health options. Please call for details.
Bring your primary and secondary insurance card(s) to each visit.
We accept assignment of insurance at the time of service. We cannot bill your insurance company unless you bring all of your information with you to each visit.
It is your responsibility to know and understand your insurance coverage as it pertains to deductibles, co-pays, pre-existing condition limitations and if we are listed as medical providers on your plan.
Please let San Tan Counseling know of any insurance changes.
Please be aware that some and perhaps all services provided may not be covered services under Medicare, Medicaid and other insurance plans.
SERVICE COSTS AND PAYMENT
For individual, couple or family therapy – $100.00 per session with MS therapist/$120.00 per session with PHD therapist.
Our providers have the ablility to set their own individual counseling fees, please call the office for specialized fee schedules
For high deductable insurances – Per insurance the deductible is patient responsibility until met. Cost per session varies according to your insurance policy.
Bring your applicable co-pay/deductible/coinsurance payment. Payment for services is due at the time of your appointment. We accept cash, check, Visa and Master Card.
Remaining balances after your insurance plan(s) have paid may be your responsibility. Our billing department will bill you the appropriate amounts in accordance with the information received on the explanation of benefits. You will also receive a copy of this from your insurance plan(s).
Payment in full is due upon receipt of your billing statement.
If you have any questions during the billing process please feel free to call our office.
It is in both parties interests to communicate about any billing issues and questions throughout the billing process and appropriate arrangements will be made based on the individual needs of each patient account.
The adult accompanying a minor will be responsible for payment in full. Minor patients not accompanied by their legal guardian will be denied services except in cases of an emergency unless the adult has a written note from the legal guardian stating the minor is under the adults care and can be seen by one of our providers.
If you have moved, changed contact information or changed insurance let us know at the time of your visit so we can update your information
All new patients will have new patient forms that need to be completed. There are two means to accomplish is; 1) show up 20 minutes prior to their appointment, or 2) print out the required paperwork off the San Tan website under Forms and come in five minutes early.
From time to time schedules can change and we understand. Please call our office 24 hours in advance to let us know if you need to cancel or reschedule your appointment or you may be charged for the visit. The charge for a late cancel, late reschedule or no show is $65.00.
We may also choose to discharge a patient for habitual late cancellations and or rescheduling. We want to serve all of our patients in a timely and efficient manner and effective communication is the best way to accomplish this.
If you show up late to your appointment, the appointment may be subject to cancellation.
Medical Records can be obtained by signing a release of records form at any of our locations. The form can be downloaded from our website under Forms. A fee of $40.00 will be charged to an outside agency other than a medical provider.
Medical providers requesting your health care information will be provided free of charge.
If the patient is requesting a copy of their own records for personal use a fee of $10.00 for up to 20 pages will be due prior to obtaining the records. An additional fee of .25 per page will be due for pages beyond 20 pages not to exceed $40.00.
Form Fees such as FMLA, Life Insurance and other forms will be assessed $100.00 per form.
Letters from your provider on the Medical Practice letterhead will be made available at a cost of $100.00.
Our offices are open Monday through Friday from 8:30 AM – 4:30 PM and on Saturdays scheduled by counselor.
We have a 24-hour emergency phone number.
Calls received outside of normal business hours, will only be returned after hours if it is an urgent matter.
All urgent calls received after hours will be responded to as appropriate to the individual need of the patient.
An after-hours fee may be charged to you for services rendered during non-business hours.