Forms and Policies
At the Counseling & Wellness Center, we make every effort to accommodate your unique situation. If you need assistance with any of our forms or policies, please reach out.
Payment for Services
Payment of deductibles, co-payments, co-insurance, and self-pay amounts are due at the time of service. As a courtesy to you, we will file your primary and secondary insurance.
In divorce situations, the parent bringing the child to The Counseling & Wellness Center for care will be responsible for all charges during treatment.
We will first send a letter requesting payment or call to discuss payment options for any unpaid balance. We reserve the right to use a collection agency. No clinical information is given to collection agencies.
Non-Discrimination/Sliding Fee Discount Policy
Download our non-discrimination and sliding fee discount policy (PDF)
Sliding fee application and fee schedule
Download our sliding fee application and fee schedule (PDF)
Case Management Service and Coordination of Care
Download an informational sheet on case management services (PDF)
Late Cancellation and No Show Fee
A $40 fee will be charged for appointments cancelled or missed with less than 24 hours notice. If you need to cancel an appointment, please call our office during business hours: Monday-Thursday 9 AM- 5 PM
Please Be On Time
Patients who are 10 minutes or later for appointments may be rescheduled. This decision will be made by the nursing staff.
Additional Resources / Forms
Why Medical Screening?
Download our flyer: Why do I need medical screening (PDF)
Psychological Testing
Download: Parent Report (PDF)
Download: Vanderbuilt Parent (PDF)
Download: Teacher Report (PDF)
Download: Vanderbuilt Teacher (PDF)
Medical Screening Instructions
Please help us to get the appropriate medical clearance needed for your intake process by completing the following steps:
Step 1: Please contact your Primary Care Physician to set up an appointment for your medical clearance evaluation
Step 2: Please Download the “Medical Screening Form for PCP” to take to your appointment with your PCP.
Step 3: Please inform your PCP about all your psychological symptoms you are having in order for them to determine is any physiological cause due to a medication or any medical condition.
Step 4: Please have your PCP fax the completed Medical Screening Form back to our office. Once we have received this document, we will be ready to begin treatment. Our fax numbers are listed on our Appointments page.