- Initial 50-minute session: $210
- Weekly 50-minute session: $180
- Legal evaluations: case-by-case
Services may be covered in full or in part by your health insurance or employee benefit plan. Please check your coverage carefully by asking the following questions:
- Is Carmen Visan, License# LH 60202825 / FEIN# 45-4001639, contracted as an in-network provider with you?
- Do I have mental health insurance benefits?
- What is my deductible and has it been met?
- How many sessions per year does my health insurance cover?
- What is the coverage amount per therapy session?
- How much does my insurance pay for an out-of-network provider?
- Is approval required from my primary care physician?
It is your responsibility to know whether you have a co-pay and whether you have met your deductible. Payment – co-payment, co-insurance, or deductible – is expected upfront, at the beginning of each session. Failure to pay at the time of each session will result in your subsequent session being cancelled.
If you do not show up for your scheduled therapy appointment and you have not notified me at least 24 hours in advance, you will be required to pay the full cost of the session.
If you’re a new client, please complete the following forms and bring them to your first therapy session.
- Client History Questionnaire – download part I, part II, part III
- Disclosure Statement – download
- HIPAA Acknowledgment – download
- Payment Agreement – download
If you would like me to coordinate care with another provider or for other like purposes (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
- Authorization to Disclose Information – download
If at any time you would like to revoke the Authorization to Disclose Information, please complete this form:
- Revoke Authorization to Disclose Information – download
Note: To download Adobe Acrobat Reader for free, click here.