Appointments

New Client Appointments

I schedule my own appointments. If you would like to talk to me about setting up an initial appointment, please call me at 608-237-8000 extension 109. You can leave a message for me at any time in my confidential voice mail.

If you are a prospective new client please note that I am not able to accept all new referrals at this time. If you would like me to make a determination as to whether I can see you, please leave information on my voice mail about the following 7 items:

  1. Your full name. Please spell your name.
  2. Contact numbers and best times to reach you
  3. How you chose me as a possible provider (for instance who referred you)
  4. Any restrictions on times you can or cannot make appointments
  5. The name of your health insurance carrier if you hope to use insurance
  6. If I have permission to leave you a voice mail message identifying myself
  7. A brief statement describing the problem you are calling about

If I am able to consider starting with a new client at this time, I will try to contact you within five business days.

Once you have made an appointment with me, Wisconsin Statutes require all clients to complete several forms before their first session. Depending on the reasons you are coming to see me, I will ask you to complete certain self tests which will be helpful in providing a comprehensive assessment for treatment.

In our telephone consultation, I will inform you as to which forms and self tests I would like you to complete for your intake appointment.

Once an intake appointment is scheduled, our Administrative Manager will contact you through the email you have provided to inform you how to access and enroll in our patient portal to complete intake forms and to get the link for your telehealth session. 

For your convenience, you can download a printable copy of each of the forms and self tests from this page or from my Forms and Test Yourself pages.

If you are using health insurance, please have your health insurance card and a photo ID for uploading into our patient portal prior to your first appointment and when there are changes.

I will review the forms and self tests with you in the initial session and answer any questions you have about them.

Nine Forms For New Clients Who Are Using Health Insurance:

  1. Billing-Insurance Information Form gives 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.
  2. 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.
  3. 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.
  4. Informed Consent Form explains informed consent as my client. (1 page) Read and sign.
  5. Health Insurance Portability and Accountability Act (HIPAA) Privacy Practices Form describes legal use and disclosure of health information. (4 pages) Read.
  6. Receipt of HIPAA Privacy Practices Form acknowledges that you have received and understand the HIPAA form. (1 page) Read and sign.
  7. Client Bill of Rights and Grievance Procedure Form tells you your rights as my client. (1 page) Read.
  8. 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.
  9. MCPST Agreement For E-Communication Form  offers clients the ability to communicate with therapists via electronic mail, patient portal, telemedicine and text notification. (1 page) Read and sign.

Eight Forms For New Clients Who Are Paying Privately:

  1. Billing-Insurance Information Form gives you information about my policies and procedures; fees for intake and ongoing psychotherapy sessions; and private pay fee agreement. (2 pages) Read, complete and sign all relevant sections of both pages.
  2. 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.
  3. 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.
  4. Informed Consent explains informed consent as my client. (1 page) Read and sign.
  5. Health Insurance Portability and Accountability Act (HIPAA) Privacy Practices Form describes legal use and disclosure of health information. (4 pages) Read.
  6. Receipt of HIPAA Privacy Practices Form acknowledges that you have received and understand the HIPAA form. (1 page) Read and sign.
  7. Client Bill of Rights and Grievance Procedures tells you your rights as my client. (1 page) Read.
  8. MCPST Agreement For E-Communication Form  offers clients the ability to communicate with therapists via electronic mail, patient portal, telemedicine and text notification. (1 page) Read and sign.

Forms Giving Permission for Client Information To Be Released:

  • 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.

 

Free Self Tests:

  • Internet Sex Screening Test (ISST) developed by Dr. David Delmonico, evaluates internet sexual activities to screen for patterns of problematic sexual behaviors which could reflect sexual compulsivity or sex addiction.

 

Fee Based Self Test:

  • Partner Sexuality Survey (PSS) developed by Dr. Stefanie Carnes to learn how sexual addiction impacts the sexuality of the partner of the sex addict.

 

Please look down this page to see my Cancellations Policy if you need to cancel your appointment and my Emergencies procedure if you are experiencing an emergency.

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Current Client Appointments

I schedule my own appointments. If you would like to schedule, change an appointment or have a question, please call me at 608-237-8000 extension 109. You can leave a message for me at any time in my confidential voice mail. I try to respond to calls within forty eight hours. You can also leave a message for me in the patient portal.

Please look down this page to see my Cancellations Policy if you need to cancel your appointment and my Emergencies procedure if you are experiencing an emergency.

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Cancellations Policy

I request that you give me at least 24 hour verbal notice for cancellations.

You can call me and leave a private confidential voice mail message for me 24 hours a day at 608-237-8000 extension 109 and you can leave a message for me in the patient portal 24 hours a day.

Please do not leave an emergency message for me on my voice mail or patient portal. Please see directions below for contacting me or the clinician on call in an emergency.

I do not charge for sessions missed with at least 24 hour notice.

I understand that sometimes emergencies or illness for yourself or your child necessitate cancellation with less than 24 hour notice. Sometimes this happens for me as well. I do not charge for this situation. I ask that you give me as much notice as possible so that I can offer this appointment time to another client who may be in need of services.

You are personally responsible for paying for appointments missed with less than 24 hour notice unless there are extenuating circumstances as described above.

Insurance will not pay for missed appointments.

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Confidentiality Exceptions

I follow all privacy practices provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as described in my HIPAA Privacy Practices form.

There are exceptions to this:

If I am convinced of any of the following I will notify appropriate authorities, i.e. social services and legal agencies, whether or not you give informed consent:

  • Danger of suicide or other self-injurious behaviors.
  • Danger of causing physical harm to others.
  • Occurrence or suspicion of child abuse or neglect.

I do this for your safety and the safety of others.

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Emergencies For My Current Clients

If you are my current client and you are having an emergency, please do not leave a message in my voicemail or in the patient portal. I may not receive the message soon enough to get back to you to help you deal with the emergency. Do not leave a message in the general mailbox or receptionist’s mailbox at my clinic.

In an emergency situation, please call our clinic number, 608-237-8000 and press 0. You will receive instructions about how to reach the answering service who will contact me or the on-call clinician who can be of assistance to you. If you prefer not to talk to the on-call clinician, you can wait for a call back from me. However, I am not always available to return your call in the time frame you desire, so please assess your needs at that time and make choices based on taking good care of yourself.

In the Dane County and Madison Wisconsin area, the Journey Mental Health Center 24 Hour Mental Health Emergency and Suicide Prevention Crisis Line 608-280-2600 may be able to help you.

If you are having a crisis in which you are at risk of hurting yourself or someone else, please call 911.

 

Emergencies If You Are Not Yet My Client

WARNING:   If you are not yet my client, please do not leave a crisis call for me in my voice mail or with the answering service.  If you are having a crisis in which you are at risk of hurting yourself or someone else, please call 911. 

If you are outside of the Dane County and Madison Wisconsin metropolitan area, the National Suicide Prevention Lifeline Crisis Line 1-800-273-8255 may be able to help you.

In the Dane County and Madison Wisconsin area, the Journey Mental Health Center 24 Hour Mental Health Emergency and Suicide Prevention Crisis Line 608-280-2600 may be of assistance to you.

On the Internet Resources – Links page I have listed contact numbers for a range of mental health services throughout the United States. You can use these links to find resources outside of the Madison area.

I am not endorsing the services of anyone on these links or resources. Please carefully screen the credentials of whatever treatment provider you choose.

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