Client Information

The Psychology Center SC is a skills-oriented clinic. Clients who work with our prescribing providers are typically required to also be engaged in psychotherapy services within our practice.

Psychotherapy and medication management services are available in-person or through our telehealth platform, Zoom. Availability of in-person or telehealth services can be affected by clinician circumstance and therapist or prescriber consideration of best practices and ethical guidelines for treatment.

Client Forms

TeleHealth Forms

All patients utilizing Telehealth services must have the following forms on file.

• Automatic Payment Plan
• Secure Messaging Agreement
• TeleMental Health Informed Consent

Registration Forms

• Automatic Payment Plan
• HIPAA (Privacy Protection)
• Health Insurance Claim Authorization
• New Client/Patient Registration
• Secure Messaging Agreement

Child & Adolescent Forms

• Child Pre-Intake Questionnaire (for new clients under the age of 14)
• Children Pre-Intake Information Form
• Parental Consent for Child Therapy

Notice of Right to Receive a “Good Faith Estimate”

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.