New Patient Instructions

We are currently adding patients to the waitlist. If you are pregnant or postpartum (from birth or loss), we will do what we can to get you in STAT.

We will use the following information to verify benefits, start a chart, and put you on the wait-list (should we have one). This also allows us to assess your needs prior to coming in.

Steps to Making a New Patient Appointment:

Please complete the new patient form below. This is very important; all new patients must have this completed PRIOR to being considered for an appointment.

**This form does not replace the new patient paperwork. This is for insurance verification and chart creation only. You will be sent a link to new patient paperwork after you have secured an appointment. Please note – new patient paperwork needs to be completed at least 24 hours prior to your appointment time to give our office an opportunity to provide you with THE best care possible.

New Patient Information

First Name *

Last Name *

Middle Name

Gender Identity *

Street Address *

City *

State *

Zip *

Primary Phone Number *

Phone Number Type

Secondary Phone Number

Phone Number Type

E-Mail *

Date of Birth (MM/DD/YYYY) *

Marital Status

Emergency Contact

Contact Full Name

Phone Number

Relationship

Work

Employer

Job Title

Phone Number

Address

Zip Code

Insurance

Will you be paying by insurance? If yes, insurance information below is required or we will consider this cash pay. *

Insurance Company

Member/Policy Number

Group Number

Insurance Contact Number

*Please upload a photo of your insurance card and ID once granted access to the portal. This occurs when you are removed from the waitlist and provided a new patient appointment.

Information of Policy Holder or Financially Responsible Party (If Not Self)

Relationship to Patient

Policy Holder or Financially Responsible Party’s Full Name

Policy holder’s Date of Birth (MM/DD/YYYY)

Phone Number

Address / Zip (If Different from Patient)

Referral Information

How were you referred to us? *

Do you want Virtual or In person Visits?

Please be advised we are 100% telehealth/virtual.

Who do you prefer to meet with for therapy? Not all clinicians can see every insurance. We will do our best to match you accordingly. If you are pregnant, we will do what we can to get you in ASAP even if we have a waitlist. If you were referred to us, we will do our best to get you seen ASAP, too. *

Do you want/need a BIPOC therapist?

What is your reason for seeking care now? If you are pregnant, please indicate how many weeks. *

Is there anything you want us to know?

Office Policy Agreement

All cancellations/reschedules made at least 24 hours in advance of the scheduled appointment are not charged. If you late cancel or no show your new patient appointment, you will not be given another appointment option with this office. After your new patient appointment, late cancellations/reschedules and no-show appointments will be charged according to the current fee. Insurance will not reimburse you for this charge. For repeated no-shows or late cancel/reschedules, all future appointments will be canceled until you are able to attend scheduled appointments without missing them.

This practice requires a credit/debit card on file to secure appointments. You will be asked to submit this number through the patient portal, which is a secure file. This card will be used primarily for copayment/co-insurance/session fees and for no-shows and late cancellations. By agreeing to the terms and providing your credit/debit card, you are acknowledging that you are aware that your card will be charged according to the office policies. After agreeing to the terms and providing your credit/debit card, if you contact your bank or card company to deny this charge, resulting in a “chargeback,” any additional fees associated with that chargeback will be added to the original missed appointment fee. Thank you for your cooperation with this necessary policy.

I agree to these office policies and give permission to charge the card on file accordingly. *

Payment:

If this practice is not in your insurance network, you can self-pay and apply to your insurance for out of network benefits.

Please note that once you have self-paid for a visit, we do not retroactively submit the visit to insurance. Please alert us ahead of your visit if you ever need to change your method of payment.

Office fees for self-pay patients:

- $197 ($224 for the first visit) with Dr. Blythe
- $95 ($125 for the first visit) with Dr. Natalie & Dr. Latasha

Payment is due at the time of service.

There is a $65 fee for no-shows and less than 24-hour notice of cancellation. If you late cancel or no show for your new patient appointment, you will not be given another appointment.

No refunds are given after a service has been rendered per the appointment policy.

We currently accept the following insurance: Aetna, Amerigroup, BCBS, Cigna, Magellan, Molina, Superior/Ambetter, TCHP (Texas Children’s Health Plan), UHC/Optum. To see which provider is on which insurance panel, please see their personal pages.

We take credit/debit cards and HSA/FSA cards.

We WILL NOT deny services for any reason – including race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity, period.

Dr. Blythe TwoSisters is a Licensed Psychologist with the Texas State Board of Examiners of Psychologists (TX License #36566; Expires 9/2021). For information on how to verify a license, please go to www.tsbep.texas.gov. For information on how to file a complaint, please go to the following page: https://www.tsbep.texas.gov/how-to-file-a-complaint-enforcement.

Dr. Natalie Caron is a Licensed Professional Counselor #62418 and is currently participating in a training program with Dr. Blythe to complete her postdoctoral fellowship required by TSBEP to become a fully licensed psychologist. Should you have any concerns, please contact Dr. Blythe for assistance – 214-997-4697.

Dr. Latasha Allen is currently participating in a training program with Dr. Blythe to complete her postdoctoral fellowship required by TSBEP to become a fully licensed psychologist. Should you have any concerns, please contact Dr. Blythe for assistance – 214-997-4697.

New Patient Instructions

New Patient Information

Emergency Contact

Work

Insurance

Information of Policy Holder or Financially Responsible Party (If Not Self)

Referral Information

Office Policy Agreement

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