Forms

Name (required)

Age

Date of Birth

Email

May I use email to contact you?
YesNo

Address

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip code

Home Phone

Work Phone

Cell Phone

Best number to reach you?
—Please choose an option—Home PhoneWork PhoneCell Phone

Please offer a name to serve as emergency contact

Phone number for emergency contact

Relationship of emergency contact

Will you take a moment to let me know how you learned of my practice? By whom were you referred?

Payment Policy: As the client, the health care insurance is yours. Insurance coverage varies widely, and it is your responsibility to know which outpatient psychology services are covered, and how that impacts your payment responsibility.
There are times when appointments are missed because of circumstances or illness. While Dr. Wolfe is happy to work with you to re-schedule, she may charge for appointments that are missed without 24 hours advance notice of cancellation.
Please understand that you are responsible for charges for services provided. In the event of non-payment, Dr. Wolfe may involve a collections agency, and you would be responsible for any additional fees related to that service.
Please note: Dr. Wolfe does not accept direct reimbursement from insurance companies. Dr. Wolfe does provide a detailed invoice for clients who wish to be reimbursed by their insurance companies. Please note that payment is due at the time of service.
It is Dr. Wolfe’s practice to give to the client the forms you will submit to your insurance for payment. If you request that Dr. Wolfe have contact with your insurance company, or that she submit claims to that entity, you hereby authorize that Dr. Wolfe release information as required by the insurance company to authorize services and/or to process claims for the payment of benefits.
Electronic Signature: Please type your first and last name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Payment Policy.