Prior to your scheduled appointment, we ask that you complete the following two forms.

Informed Consent/Payment Policy Statement

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

OFFICE HOURS - Please understand that this is a private practice and Dr. Burns may not be immediately available in psychiatric emergency. If you are unable to reach Dr. Burns, please contact a crisis line or go immediately to the nearest emergency department.

SESSIONS - Sessions are typically scheduled for 30-60 minutes at a frequency determined together. We will work together to develop goals on which you want to work. Dr. Burns will act as a facilitator of change.

CANCELLATIONS - Dr. Burns understands, at times, it may be necessary to cancel an appointment. To help us be most efficient and responsible in the use of our time, changes or cancellations must be made at least 24 hours in advance. Any changed, cancelled, or missed appointments with less than 24 hour notice will be charged a fee of $50.

CONFIDENTIALITY - You, the Client/Responsible Party understand that all communications between you and Dr. Burns are confidential and will not be shared with anyone unless a release of information is signed. Times confidentiality may be broken are the following, in which a therapist is bound by state law to inform the appropriate authorities - If you, a child, or an elderly person is being emotionally, sexually, or physically abused or neglected - If someone mentions a serious threat to your own life or thelife of another - If ordered to do so by a judge of a court of law.

INSURANCE - You, the Client/Responsible Party may request Dr. A. Monique Burns, PhD, ACSW, LCSW, LSCSW or PSU, LLC to bill your insurance. In doing so, you agree to allow our office to disclose your dianoses and all other clinical information related to your therapy if requested by your insurance provider. Yourtherapist is required to make medical diagnosis for insurance billing purposes. Sharing of medical information with your insurance company can potentially affect your rates or insurability. If you wish to avoid disclosure of personal treatment information to your insurance company, you have a right to privately pay for your services.

PAYMENT POLICY - You, the Client/Responsible Party are responsible for payment. You are responsible for knowing your co-pay or co-insurance as determined by your insurer and for paying this amount at each session. If you have agreed to cask payment or have a deductible that has not been met, my fees are $85 for individual sessions and $125 for couples and family sessions.

FORM COMPLETION - Letters to employers, eommunication with Social Security and other third parties, an appointment will need to be scheduled to cover this time and a fee of $50 is charged for each letter/form.

FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT - The undersigned, "Client/Responsible Party", has read the preceding information and understands their rights as a client. The undersigned authorizes release of any medical or other information necessary to process a 3rd party insurance claim for services rendered at PSU, LLC. The Client/Responsible Party authorizes payment of medical benefits to the undersigned Therapist for services rendered, and the signature acknowledges agreement and understanding. Permission is hereby given to render treatment or service to:

Client Signature

Signature of Therapist

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Prior to your scheduled appointment, we ask that you complete the following two forms.

Client Information Form

Informed Consent/Payment Policy Statement