All Forms
The information collected in these forms is held strictly confidential and is to sensitive to be emailed. Please download and fill out the following forms. There is a form at bottom of this page under the "Services and Consent for Treatment Form". This form should be filled through the website.
PATIENT INFORMATION FORM - download the file
Patient Release- DOWNLOAD this Form
PAYMENT POLICY FORM- download
CREDIT CARD PAYMENT FORM - download
Services and Consent for Treatment Form
This document contains important information about my professional services and policies. Please read it carefully and make note of any questions or concerns you have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
OFFICE HOURS & SESSION TIME: Sessions are scheduled by appointment only. Sessions will range from 15 minutes to 90 minutes in length and begin on time. If I am late for a session, I will make up for the lost time by either extending that session accordingly or by adding the time onto a following session, whichever option works best for both of our schedules. If you are late for a session, in most cases the session will end at the scheduled time.
MISSED APPOINTMENTS & MAKE-UP SESSIONS: Continuity and consistency are important factors in creating and effective and meaningful experience. If a session is missed or canceled with less than 48 hours notice, you will be charged for the half the full fee session. If the session is cancelled with less than 24 hours notice, your will be charged for full fee for the session. This cancelation policy is subject to change.
BILLING & SESSION FEES: You will be expected to pay for each session at the time it is held. I accept cash, check or credit card. A pattern of non-compliance with payment may result in termination of treatment. As I am a licensed and board certified Psychiatrist in the state of New York, you can obtain reimbursement for the cost of our sessions if you have a health insurance plan that will pay for services rendered by an out-of-network mental health provider. Please check with your health insurance company to discern whether (and how much) they will reimburse you for these services. You should be aware that your health insurance may require that I provide them with clinical information relevant to the services rendered. In these situations, I will discuss this with you and release only the minimum information necessary.
COMMUNICATION BETWEEN SESSIONS: If you need to contact me between our sessions, please call me at 917-881-6516. If I am unavailable to speak when you call, please leave me a message on my confidential voicemail and I will return your call as soon as I can. I am usually available to return messages within 24-48 hours, with the exception of Saturdays, Sundays, Holidays and my vacations. I may not have your number accessible, so please leave me the phone number where you can be reached, even if you think I already have it, and some times that you will be available. If I am away for an extended period of time, I will provide you with the name of a colleague to contact if necessary. I use email only for scheduling and billing related matters. Email should not include clinical information and should not be used for urgent or emergency situations. Please notify me if you do not wish to use email for scheduling and billing related matters. I do not communicate via text message. Please notify me if you do not wish to be contacted via email. If you are calling me for a medication refill authorization request I will need your full name and DOB with the pharmacy number. If you miss your appointment, and need a 5 day supply of medication called in, I do bill for this service. I will do this only on occasion and in the care of emergency.
EMERGENCY PROCEDURES: If an emergency (i.e., life threatening) situation arises and you cannot reach me, please call 911 or go to your nearest emergency room. Please also leave me a message regarding the situation and where I can reach you as soon as it is feasible.
CONFIDENTIALITY: All information that you share with me is strictly confidential. Exceptions to my commitment of your confidentiality are as follows:
· You authorize a release of information/records through signed and written consent.
· You present a physical danger to yourself.
· You present a physical danger to others.
· You disclose information that provides evidence of abuse or neglect of a minor-age child or elder. By law I must report this information to the appropriate protection agency.
· In certain legal proceedings, confidential treatment information may be mandated by court order. This is a rare occurrence and would not happen without your knowledge.