Name
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First Name
Last Name
Pronouns
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Email
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Phone
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Location
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Referred By
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Your commitment to this work will likely require 1-2 weekly meetings of 50-75 minutes each - scheduled on weekdays - in addition to any other work, family, and social obligations you may have.
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CONFIRM YOUR UNDERSTANDING & AGREEMENT
Your investment for Individual Therapy and Couples Therapy will be $235 per 50-minute session. Your investment for Group Therapy will be $100 per 75-minute session. Our rates are subject to change annually.
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CONFIRM YOUR UNDERSTANDING & AGREEMENT
Our practice uses a secure, HIPAA-compliant patient portal where you will be required to keep valid billing information on file. We automatically charge you on the day of your session (or on the day of your canceled/missed session, in accordance with our Cancellation Policy).
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CONFIRM YOUR UNDERSTANDING & AGREEMENT
Our practice does not accept insurance. We provide insurance holders with monthly Superbills to submit for out-of-network benefits. We do not get involved with insurance companies and we automatically charge you for services in full, regardless of when you are reimbursed.
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CONFIRM YOUR UNDERSTANDING & AGREEMENT
Our practice observes a strict cancellation policy. We require 7-day notice for any cancelations or schedule shifts. We automatically charge you in full for sessions that are canceled with less than 7-day notice unless the sessions can be rescheduled within the same calendar week (subject to availability, which is not guaranteed).
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CONFIRM YOUR UNDERSTANDING & AGREEMENT
Our clinicians have very limited availability, which may shift quarterly in alignment with our scheduling process. Availability may also shift unexpectedly due to factors beyond our control (illness, school closures, etc.). While we make every effort to avoid this, any shifts to clinician availability require affected sessions to be canceled/rescheduled on short notice.
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CONFIRM YOUR UNDERSTANDING & AGREEMENT
What form(s) of therapy are you inquiring about?
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SELECT ALL THAT APPLY
Which topic-specific group(s) are you interested in?
SELECT ALL THAT APPLY
If you are interested in any topic-specific group(s) not listed above, please specify:
Would you prefer telehealth or in-person sessions?
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Would you like to connect with us before scheduling an initial session?
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What is your general availability?
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SELECT ALL TIMES YOU ARE AVAILABLE
What prompted you to make this inquiry?
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What are you hoping to accomplish in our work together?
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What additional information (if any) would you like us to know to evaluate if you are a good fit for our practice?
What additional information (if any) would you need to know to discern that our practice is a good fit for you?
What questions do you have for us about our practice or anything else in this form?
Please check this box if you would like to be added to the Lisa Kays email list.
While we make every effort to maintain the highest level of security across all platforms we use at Lisa Kays PLLC, please note that electronic forms of communication are never 100% secure. Please also note that we collect, process, and store your data according to our Privacy Policy and that submitting this form constitutes your full understanding of and agreement with these terms.
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Please read our Privacy Policy at www.lisakays.com/privacy.
