Client Forms

There are two mistakes one can make along the road to truth...not going all the way, and not starting.

- Buddha

Please read carefully...

Fees & Billing Practices

This practice collects payment in full through personal check, cash, debit or credit cards (except for American Express) at the time of service. At the close of each appointment, you will receive a "superbill". This form contains the required information for your insurance company to reimburse you.  You can attach a copy of the superbill to your insurance form and send it in to your insurance carrier.

I am an authorized "out of network provider" for many insurance companies, since I am a licensed psychologist in North Carolina (termed a “Health Service Provider-Psychologist”). This means that there are benefits through your insurance or benefits coverage to which you may be entitled as reimbursement for my services. Please talk with your insurance carrier or employee benefit program administrator to better understand the terms of your mental health coverage.

New Client Forms

As advised by my office manager, please download the specific documents for the packet you need to bring with you to your initial consultation session. Packets are provided for "Children Under 6 years of age";  "Children Over 6 years/Teens"; and for "Adults".

All clients please download and make a copy for your files:

1. Client Agreement Form
2. NC Notice Form
3. Schedule of Fees

Now select, download and fill out the appropriate packet of forms below and bring them to your initial meeting:

• Children Under 6 years:

1. Child/Teen Information Form
2. Child Notice & Consent Form
3. Early Developmental Questionnaire
4. Client Appointment Cancellation Form

• Children Over 6 years & Teens:

1. Child/Teen Information Form
2. Child Notice & Consent Form
3. Developmental Questionnaire
4. Client Appointment Cancellation Form

• Adults:

1. Adult Information Form
   
2. Adult Consent Form
3. Adult Questionnaire
4. Client Appointment Cancellation Form

Only when requested by the office staff, please download the following form. Both parents/legal guardians must sign and return the form to Dr. Heiko's office before an initial consultation can be scheduled.

• Shared Custody Agreement Form

Sandplay™ Process and Consultation Clients please download, fill out and bring to our initial session all Adult Forms as well as the following form:

• Sandplay™ Background Information Form

© 2010 Dr. Heiko. All Rights Reserved.