PAYMENT & FORMS

Resources for Clients

Therapy services may be covered in full or partially based on your health plan.

Please check your healthcare coverage before your initial session. Also, you may want to ask your provider the following questions:

  • Do I have outpatient mental health benefits?
  • Are there limits to the mental health therapy I am able to receive, and if so what are they?
  • Do I have to choose a therapist from a specific provider list, and if so is your therapist on it?
  • Do I have a deductible and if so, has it been met?
  • Do I have a copay and if so, how much is it per session?
  • How many sessions per calendar year does my plan cover?

Payment Methods

Cash, checks, and credit cards (Visa, MasterCard, American Express, Discover) are all acceptable methods of payment.

Payment is due when services are rendered.

Client Forms

Please find all the forms you will need for your initial consultation below. For your convenience, you can fill all of the forms out online and e-mail them back to your preferred provider, or, print out these forms to fill out to bring with you to your initial consultation.

To complete the online forms, please save the forms to your computer and complete using Adobe Acrobat. For more information and help, please visit: 

How to Fill out and Sign a PDF document
Download Adobe Acrobat

Client Information

Before your initial consultation, please take a moment to fill out the Client Information Form so we can be prepared to help serve you better.

CLIENT INFORMATION FORM

Client Insurance Information Form

Download Form

Policy for Electronic Communications

Download Form

Intern Informed Consent and Therapy Agreement

Download Form

Consent to Treatment of Minors

Download Form

HIPAA Privacy Notice & Authorization Form

Download Form

Informed Consent & Therapeutic Agreement for Psychotherapy Services

Download Form

Authorization for Release Exchange of Information

Download Form

Group Therapy Agreement Form

Download Form

Group Therapy Client Information Form

Download Form

Release of Liability for COVID-19

Download Form

Would you like to talk? Contact us to schedule your initial consultation.

East End Office

1789 South Braddock Ave., Suite 350Pittsburgh, PA 15218

Phone: 412-450-0518
Fax: 412-727-7475
Email: info@centerforrelationalchange.com