Patient Forms Appointment Interest Form / Fee Schedule Name* Today's Date*Under each type of appointment that you think might apply, please check the best days/times for you to meet and the typical frequency of sessions you expect (we will need to agree on the clinical appropriateness of these choices).BEST DAY / TIME Medication focused 25‐30min @ $300Monday morningMonday afternoonTuesday morningTuesday afternoonTuesday nightWednesday morningWednesday afternoon Medication‐Therapy 40‐45min @ $350Monday morningMonday afternoonTuesday morningTuesday afternoonTuesday nightWednesday morningWednesday afternoon Medication‐Therapy extended 55‐60min @ $400Monday morningMonday afternoonTuesday morningTuesday afternoonTuesday nightWednesday morningWednesday afternoonTYPICAL FREQUENCY Frequency - Medication focused 25‐30min @ $300Every 2 weeksEvery 1 monthEvery 6 weeksEvery 2 monthsEvery 3 monthsEvery 4 months Frequency - Medication‐Therapy 40‐45min @ $350Every 2 weeksEvery 1 monthEvery 6 weeksEvery 2 monthsEvery 3 monthsEvery 4 months Frequency - Medication‐Therapy extended 55‐60min @ $400Every 2 weeksEvery 1 monthEvery 6 weeksEvery 2 monthsEvery 3 monthsEvery 4 monthsInitial Evaluation90min.+ @ $500 (two sessions required, includes intake administration and extensiveformulation of diagnoses/treatment plan to be shared as a summary)Paperwork fee15min.+ @ $150 (involved work outside of ongoing appointments and email interactions) reCAPTCHASubmitReset
