Patient Information Sheet

Before your initial visit please complete the Client Intake form, this Patient Information form, the consent to treatment form and read and sign acknowledgement of the HIPAA regulations form. Please scan completed forms to debra@debraalper.com.

Appointments

Appointments will be scheduled at a time acceptable to both the patient and the therapist and last 53 minutes. Typically, clients are seen once a week. All sessions are telehealth.

Fees

Federal Truth in Lending Disclosure Statement for Professional Services

Part One - Fees for Professional Services

I (we) agree to pay Debra Alper, LCSW of Life Transitions Counseling, PLLC, a rate of $275/clinical unit (defined as 53 minutes session) for counseling. Payment is due at the time of the session by Zelle.

I agree to the fee structure and payment terms specified above.

Part Two - Cancellation Policy

There is a 48-hours’ notice cancellation policy. If you cancel a scheduled appointment with less than 48-hour notice, you will be charged a $275
cancellation fee.

I acknowledge and accept the 48-hour cancellation policy and fee.

Part Three - Clients using Medical Insurance

I am in network with BCBSIL PPO. All co-pays and co-insurance payments are due at the end of every session. Any late cancelled sessions or missed sessions cannot be submitted to insurance and the client will be responsible
for payment directly to me.

I understand my financial and coordination responsibilities regarding medical insurance.

I HEREBY CERTIFY that I have read and agree to the conditions and have read the Federal Truth in Lending Disclosure Statement for Professional Services.

I HAVE READ THIS PATIENT INFORMATION SHEET AND UNDERSTAND THE REQUIREMENTS AND RULES OF THIS OFFICE. I AGREE TO THE TERMS THEREIN AND GIVE MY CONSENT TO THE EVALUATION / TREATMENT PROCESS WITH Debra Alper, LCSW.

Person responsible for account:

Date:

Download: Patient Information Sheet

Patient Information Sheet