Request for services
the contents of this submission are secure
1. I am an adult age 18 or older and am seeking services for myself.
2. I am seeking psychotherapy for one of the following reasons listed on the practice’s website.
a. Seeking individual Christian-based psychotherapy from a Biblical worldview
b. Seeking cognitive-behavior therapy (CBT) to address depression; anxiety; anger; generalized anxiety; Posttraumatic Stress Disorder (PTSD); panic disorder; social anxiety; insomnia or sleep problems; stress; or Attention-Deficit/Hyperactivity Disorder (ADHD)
c. I am a pastor seeking individual psychotherapy
d. I am a college or professional athlete or coach
e. Other problem area as listed under Dr. Wise’s Focus on the Family or other online profile.
3. I understand that services with the practice are delivered 100% in video tele-health format, I have internet access, and I am comfortable working with video tele-health format. I understand that this practice does not offer services in a traditional face-to-face office setting.
4. I understand that the practice requires that I am a New York resident and must be physically present in New York when services are received; I understand that my presence in New York will be verified by my self-report; electronic signature; and via the video tele-health program at each session.
5. I am not a member of the U.S. military or military dependent; do not participate in HUMANA, Tricare, or Martin’s Point insurances; and I am not a member or the U.S. military or military dependent who participates in MEDICARE or MEDICAID programs. I understand that Dr. Wise is unable to provide services to U.S. military members and military dependents; individuals who participate in HUMANA, Tricare, or Martin’s Point insurance plans; or U.S. military or military dependents who participate in MEDICARE or MEDICAID programs.
6. I understand that this practice does not offer emergency or crisis services. In cases of emergency, I will seek services by calling 911 or presenting to my local hospital emergency room.
7. I desire to complete an initial assessment to assess symptoms, problem areas, and determine if the practice is the right fit to assist me to meet my needs and accomplish my goals. I understand that there are some situations in which someone may need services not offered in this practice, as listed on the website. Some examples in which someone would be a better fit for another setting and not this practice include those needing higher level of inpatient care; safety concerns such as suicide thoughts; chronic re-occurring suicide thoughts; substance abuse problems; severe eating disorders; and those in need of a face-to-face clinic setting that offers both psychotherapy and psychiatric medication management services.
8. I agree to the terms of billing/payment as listed on the practice’s website. I understand that the practice does not participate in any insurance plans. I understand that full payment is due by credit card at the beginning of each session. Costs for sessions include $150 for the initial assessment and $125 for each psychotherapy session. I may request a superbill for me to submit to my insurance company for consideration, but I understand that full payment is my responsibility and this practice does not participate in any insurance plans.
9. I understand that to participate in the practice and receive services, I agree to use the practice’s secure client portal to complete important documents needed for the practice. I agree to provide an email address, which will be used to later activate the portal once I set-up my initial appointment. Once the portal is activated (later, not at this time), I will get a generic email from ‘Advanced Wise PS’ about the portal.
10. I wish to proceed and set-up an initial evaluation. By agreeing to the above terms and submitting this document, I will be contacted by the practice to set-up an initial appointment. I will not be charged anything at this time. Payment for services is due at the time services are received.
11. Name: *
12. Phone: *
13. Email: *