Clinical & Forensic Psychiatry
Patient Form & Payment Info.
Please Print and Fill out this Form:
FAX it me at 970-987-5100. Or scan it into your computer and e-mail it to me at:
Adult Civil and Criminal
OFFICES: Eureka Springs
3 Digit Code:
Current Medications & Allergies: list drug allergies, drugs being used and dosage on back of page
PAYMENT MUST BE MADE AT TIME SERVICES ARE PROVIDED.
VISA and MASTER CARD CARDS ACCEPTED, but you are responsible for all charges, if your credit card company does not pay for any reason.
I will provide bills at least monthly, which will include the information needed for you to be reimbursed by your medical insurance company.
Continuing to prescribe most medications will require periodic in-person visits to examine for optimal effectiveness, side- effects and newly available alternative drugs.
I schedule only one patient for each hour, so an appointment which is not kept wastes an hour that another patient might have used. The more notice I get of a cancellation, the greater the chance that I will be able to use that time for another patient. If you cancel less than a week in advance and I cannot use the time I have reserved for you, or if you just do not come in, the session charge will be charged to your credit card.
Please read information on the second page and keep a copy.
I have read, understood and accept these patient responsibilities. I agree that I will be responsible for all treatment charges, including accepting the policy on cancellations.
I am an Assciate Professor at the University of Arkansas for Medical Sciences.
In addition to the usual three [sometimes four] years of psychiatry residency, I took another nine years of half-time training in San Francisco and at the University of Colorado Health Sciences Center in Denver where I have taught psychiatry/advanced psychotherapy as an Associate Clinical Professor. This training has allowed me to qualify for three Board Certifications in psychiatry/ advanced psychotherapy, as well as a tenured faculty position at the Center for Advanced Psychoanalytic Studies, meeting at Princeton.
Clinical fees must be paid at time of the appointment.
Forensic Evaluations: One-half of estimated cost is due when evaluation begins with the balance due on presentation of the Report.
Expert Witness Testimony: Estimated cost due prior to deposition or courtroom testimony,