Request for Services

* Indicates required field

CLIENT INFORMATION

Legal Name of Client *

First

Last

Client Date of Birth *

Sex *

Female Male

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Briefly Identify Goals/Expected Outcomes *

IF CLIENT IS A MINOR

Name of parent/Guardian if client is a minor *

First

Last

Phone Number *

Email *

Name of parent/guardian if client is a minor *

First

Last

Phone Number *

Email *

FAMILY/COUPLE'S COUNSELING

Name of Partner/Spouse if requesting Couple Therapy *

First

Last

Names of other participants (& relation to client) if requesting family or group therapy *

REQUESTED SERVICES

Service(s) Requested *

Individual Adult Counseling (18yo +) Youth/Adolescent Counseling Couples/Family Counseling

Appointment Preference - Day *

Appointment preference - Time (Eastern Time) *

Site Preference *

Virtual (video sessions) In-person (280 Talcottville Rd, Vernon CT)

In-person sessions available on Wednesday & Thrusdays

RATES and PAYMENTS
Payment is due at the time of service. Please indicate preferred payment method so our office may provide appropriate instructions for making your payments. You may always change your preference later.

STANDARD COUNSELING RATES

Individual
$200/50 minute session
Sliding Scale $40-70

Couples/Family
$250/50 minute session
Sliding Scale $65-90

TERMS AND CONDITIONS FOR USE OF INSURANCE:
The client gives Monarch Therapeutic Services LLC/Beverly T Chevalier, LCSW permission to release information to and, to receive information from, insurance plan for the purposes of coordination of services and payments. The client understands that they are responsible for letting Monarch Therapeutic Services, LLC/Beverly T Chevalier, LCSW know of any changes to their insurance. The client understands that they are responsible for the payment of services that their insurance company denies payment for. The client understands that they are responsible for all co-payments, deductibles, out-of-pocket expenses, and/or other charges that their insurance plan does not cover.

Upon submitting this form, the client/insured agrees to the above terms and conditions for use of insurance. *

Agree Not Applicable

TERMS AND CONDITIONS OF SERVICES:

If the client fails to appear for an appointment without a 24-hour notice of cancellation, a $50 no show/late cancellation fee will be charged.
If the client arrives late to their session, the session will end at the time originally scheduled and the session will not be pro-rated.
If the client arrives more than 10 minutes late for their scheduled appointment and did not make prior arrangements with the therapist their appointment may be forfeit. If the appointment is forfeit, the client will be charged a $50 no show/late cancellation fee.
The client is financially responsible for services outside of those specified in this agreement (including, but not limited to: phone calls lasting exceeding 10 minutes, emails requiring extensive review and response, records review, forms completion, letters and reports, and professional consultations) at times other than the scheduled session. These services will be billed at $25 per 15 minute increment.

UPON SUBMITTING THIS FORM THE CLIENT AGREES TO THE ABOVE TERMS AND CONDITIONS OF SERVICES *

Agree

Submit