Tammy L. Corrales, M.A., LPC, PC
302 E. Valley, Suite 3 ◊ Georgetown, TX 78626 ◊ 512.470.4419 office ◊ 512.591.7814 fax
REQUEST FOR SERVICES
Client’s Name: ______
Parent/Guardian (if client is under 18): ______
Client address: ______Email: ______
City: ______State: ______Zip: ______
Home phone: ______Work phone: ______Other: ______
Is it okay to leave messages? Home: □ Yes □ No Work: □ Yes □ No Other: □ Yes □ No
Client’s DOB: ______/______/______Age: ______Sex: □ M / □ F Marital Status: □M □S □ D □W
Client status: □ Employed □ F/T Student □ P/T Student □ Work at home
Occupation: ______Employer: ______
If client is minor: Grade in school: ______School attending: ______
If client is minor: Mother’s Occupation: ______Employer: ______
Father’s Occupation: ______Employer: ______
Please list the names and ages of all members of the client’s immediate family system
(i.e., children / siblings / parents / spouses / extended family members / significant others, etc…)
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Please list the name, age, and relationship of any other household members:
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In case of an emergency, notify: ______
Phone: ______Relationship: ______
How were you referred? ______
Is client currently taking medication? □ Yes □ No If so, name(s) & dosage of the medication(s):
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Has client received previous psychiatric treatment? □ Yes □ No
If yes, name provider and date(s) of service: ______
Reason for termination: ______
Presenting problem or condition (current): ______
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Presenting factors (contributors): ______
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Symptoms (describe): ______
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TYPES OF SERVICE and RELATED FEES INCLUDE:
(Please indicate the type of service for which you are seeking.)
_____ $225 for an initial session (typically 60-80 minutes in duration)
_____ $150 per 50-minute session thereafter for individual psychotherapy sessions conducted in office
_____ $200 for 50-minute EAP session (currently conducted Coombs Arena in Hutto, TX)
_____ $300 for 90-minute EAP session (currently conducted Coombs Arena in Hutto, TX)
_____ $150 for individual NWFF therapy sessions
_____ $180 for 80-minute couple or family psychotherapy session (This includes NWFF family participants.)
_____ $50 for 80-minute group psychotherapy session
_____ $225 for 80-minute co-parenting sessions (This includes PC/PF joint sessions)
_____ $200 per hour for court testimony (paid in the form of a retainer required a minimum of 48-hours in advance)
_____ $1,000 retainer fee for Parent Coordinator /Parent Facilitator services (typically split equally between parents)
_____ $3,000 retainer fee for Guardian Ad Litem services (typically split equally between parents)
_____ $200 per page for any written reports
Please note: Full fee will be charged for missed sessions and sessions cancelled with less than 24-hour notification.
Payment is due in full at the time of service.
1. By signing this form, you are acknowledging your understanding of the fees required by Tammy L. Corrales, MA, LPC-S in order to provide services to you.
2. By signing this form, you are accepting responsibility for payment for any of the above listed services provided to you by Tammy L. Corrales, MA, LPC-S.
3. Although I am not a contracted provider with any insurance company, I am able to provide you with a walk-out statement which allows you to submit your own claims for reimbursement of services eligible under your out-of-network benefits coverage. Please note, that insurance reimbursement requires an assigned diagnosis for treatment. Should you qualify for an appropriate diagnosis, any such diagnosis assigned as a part of this treatment will become a permanent part of your medical file.
4. Insurance companies do not pay for missed sessions or phone time. You will be responsible for fees associated with missed sessions and any phone conversations beyond 10 minutes.
Client’s Printed Name: ______Date: ______
Signature : ______
Client’s Printed Name: ______Date: ______
Signature : ______