Psychotherapy,
Sex Therapy and Sexual
Addiction Treatment in the Greater Madison Wisconsin Area

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verified by Psychology Today verified by Psychology Today Directory

 

   

name
MSSW, LCSW, SC, CSAT
Certified Sex Addiction Therapist



Reclaiming Sexuality...
Reclaiming Your Life
One step at a time
 
 

Forms


  • Billing-Insurance Information Formgives you information about my policies and procedures; fees for intake and ongoing psychotherapy sessions; private pay fee agreement; assignment of benefits for insurance; asks about client and insurance information. (2 pages) Read, complete and sign all relevant sections of both pages.
  • Credit Card Payment Authorization Form provides the option for you to charge your session fees, copays, deductibles and balances directly to your credit card. (1 page) Read, complete and sign.
  • Intake Questionnaire asks for information about you, the issues that bring you in to see me and your treatment goals so that I can best provide services for you. (2 pages) Complete entire form.
  • Informed Consent explains informed consent as my client. (1 page) Read and sign.
  • Insurance Benefits Worksheet provides information and questions to ask your insurance company to get accurate information about your mental health benefits. (2 pages) Complete and use as reference when calling insurance company to clarify benefits.
  • Authorization For Release of Information authorizes release of information to and from another person, for example psychiatrist or former therapist, for your benefit, i.e. in order to coordinate services for you. (1 page) Read and complete name, contact information and dates of contact for person with whom I will share information. I will complete the rest of the form with you in my office.

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Shari Cohn, MSSW, LCSW, SC, CSAT
Certified Sex Addiction Therapist
Midwest Center for Psychotherapy and Sex Therapy
6300 University Avenue Suite 125
Middleton, WI 53562

(Next to Madison, Wisconsin)

608-237-8000 Ext 109

 

 

Copyright © 2006 - 2017 Shari Cohn, MSSW, LCSW, SC, CSAT