• REGISTRATION INFORMATION

  • INSURANCE INFORMATION

    (please skip to the next section if you are paying privately)
  • Secondary Insurance Information (if applicable)

  • Policy Holder's Address (if different from above)

  • PRIVATE PAY INFORMATION

    (please skip if you are paying with insurance)
  • POLICIES

  • The Center for LifeSkills and Stefanie J. Peck, M.A. CCC-SLP require payment at time of services for office visits. Payments must be made by cash, check or credit.
    • I understand that I am ultimately responsible for paying my entire bill should any third-party payor deny payments for any reason.
    • I understand that payment is required at the time of service, by cash, check or credit, unless alternate arrangements are made. In some instances, an invoice will be sent. Invoices are due within 30 days of being sent
    • I understand that there will be a $25 charge for balances that are 30+ days past due (due date determined by date of session or date of sent invoice, whichever is applicable).
    • I understand my insurance benefits, including my deductible, co-pay, co-insurance, and session/visit limits. I agree to keep track of the number of sessions attended and understand that I am responsible for paying for any sessions that my insurance does not cover. My insurance company is ultimately responsible for how claims are processed.
  • HIPAA

  • The Center for LifeSkills/Stefanie Peck Notice of Privacy Practices
  • CANCELLATIONS

  • I agree to notify my therapist of any vacations/scheduled absences, so that make-up sessions can be scheduled. Advance notice is appreciated, as we can use those time slots for other make-up sessions or meetings.
    • I understand that there will be a $45 charge if a session is missed without notification. I must notify my therapist about a cancellation at least 8 hours in advance of the scheduled appointment to avoid the $45 charge. I understand that this fee cannot be paid for by a third-party payor and will be my responsibility.
  • CONSENT TO TREAT

    • I have read the above policies and agree to the terms. I consent to treatment for my child(ren),
  • by Brenda Richards, Stefanie Peck, or other therapists/student clinicians associated with them.
    • I give permission for the therapist to accompany my child to the bathroom if necessary.
  • MEDIA RELEASE

  • I give permission for my child to participate in photos and videos for media/marketing purposes for The Center for LifeSkills/Stefanie Peck. My child’s first name, photo, and/or video may be used and seen in printed marketing materials, website content, and/or our Facebook business page. Media will not be shared with any third parties. This release will remain active until I notify The Center for LifeSkills/Stefanie Peck.
  • This field is for validation purposes and should be left unchanged.