Love Comes First Family Therapy

"...fostering healing from the inside out"

Phone: (661) 889-4638

Form

Initial Client Questionnaire

Emergency Contact

New Page

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FINANCIAL AGREEMENT AND BILLING INFORMATION: Your initials indicate that you understand and agree to these policies.

A. Elizabeth Deeths, LMFT is an independent, private, fee for service provider of psychotherapy. As such, she does not receive any public monies to provide therapy. She is not affiliated with any charity, group or insurance company, although she may be a preferred provider for some managed care organizations.

B. Payment/copayment is expected at the time of services rendered, unless other arrangements have been made. Cash, check or credit card is the only type of payment accepted.

C. If I am a preferred provider for your insurance, this does not guarantee payment. Ultimately, if your insurance or managed care organization does not pay for your treatment visits, you the patient are responsible for the cost of therapy. Often, a patient believes (s)he is covered for therapy when (s)he is not, or the coverage is more limited than the patient believed. Elizabeth Deeths, LMFT will make determined and reasonable effort to collect from your insurance company or managed care group. You understand and agree that you, the patient, are responsible to pay the therapy bill if the insurance company or managed care company refuses to pay for any reason.

INSURANCE INFORMATION:

I give permission for Elizabeth Deeths, LMFT to release any information necessary for the purpose of claiming insurance, or other third party benefits, and I authorize payment of those benefits directly to Elizabeth Deeths, LMFT, 5401 Business Park, South #208, Bakersfield, CA 93309. I understand that I am financially responsible for any portion of the cost of the services not covered by third-party benefits.