Parent Information

 

 

What is the process?

After an initial phone call, I set up a parent meeting. This gives us the opportunity to talk openly about your child and I take a social and developmental history. The more information I have about your child, the better I can understand their behaviors and gain insight into their emotional world. If your child is struggling at school, a school observation is recommended. Although I am flexible, I recommend a four/five session evaluation which includes feedback for the parents. The feedback session includes my observations, parent coaching, recommendations and insight into your child's world.

 

Recommended Evaluation: 

1) Parent Meeting

2) School Visit (if needed)

3) Family Play Therapy Session

4) Individual Play Session

5) Parent Feedback

 

 

Below is paperwork that can be printed out for you to bring to our initial meeting. I will review the paperwork and I will answer any questions you may have at that time. Feel free to email me at tammi@mainlineplaytherapy.com or call my office at 610-642-1144.

 

Forms:

Child Intake Form:

This form is essential in maintaining the appropriate information about your child for evaluation and treatment.

 

Consent to Treatment:

I cannot see your child unless this form is completed. This forms explains important policies about Main Line Play Therapy. This form must be signed if your child is under 14 years of age. If you and your partner are divorced and both have legal custody, both parents need to sign this form. If you or your child is participating in Telehealth  click here for Telehealth Consent to Treatment form.

 

Release of Information:

This form gives me permission to communicate with another provider from your child's teacher to pediatrician. This form can always be filled out after meeting to make the best plan.  I work closely with school professionals and others involved with your child. I am a believer that it "takes a village" and it is important for everyone to be on the same page.

SMS & Email Consent: 

This form is used to obtain consent to communicate with you via email or text. Transmitting client information by SMS and emails has a number of risks that clients should consider before granting consent.

Payment Authorization Form

Schedule your payment to be automatically deducted from your bank account or charged to your Visa, Master Card or American Express after each session. Just complete and sign this form to get started.

Nature Consent Form:

This is an optional consent if you give permission to have services outside of the office. I love to use nature-based play therapy with children. Services rendered outside the office include varied nature-based child counseling and play therapy interventions. Although, every reasonable precaution will be used by this provider, confidentiality for your child/family cannot be fully guaranteed in an outdoor environment. 

 

Custody/Access Dispute Contract

TESTIMONY for Divorce, Custody, and Visitation/Parental Access 

Main Line Therapy. LLC - DBA Main Line Play Therapy does NOT participate in custody hearings, custody/access disputes, visitation, or divorce proceedings.  These matters are not within our scope of practice.  Please contact a Parent Coordinator or another neutral party to assist you in this matter.  We have an excellent referral source should you need forensic mental health assistance. Please print and sign the contract if this pertains to your family situation.

 

Rates and Insurance

 

As an out of network provider, I do not accept insurance. Statements can be submitted to your insurance agency for reimbursement. I will generate a statement that you can submit directly to your insurance carrier.  Please check with your insurance to see if you are covered and what the reimbursement would be.

 

Questions to ask your health insurance company:

  • Do I have mental health insurance benefits for my family?

  • What is the reimbursement for an out of network provider?

  • How many sessions per year will my insurance cover?

  • Do I need to meet a deductible? If so, how much?

 

 * Sliding scale fees are available on a limited basis

 

Payment:

Cash, Check, Credit or Debit Cards are acceptable forms of payment. Payment is requested at the time of session.

  

CANCELLATION POLICY for all Individual and Family Sessions 
I have implemented a cancellation policy to benefit all of our clients.  I truly value your time and our time together and ask for a 24 hour notice for schedule changes and cancellations so that  can provide that time slot to another person in need. Please give at least 24 hours notice of your scheduled appointment or you will be charged the full fee of the session.

 

LEGAL FEES DISCLOSURE 
Please be advised that Main Line Therapy, LLC - DBA Main Line Play Therapy has a Legal Fees Policy for any legal or court related involvement with your case.  These include a base retainer fee, all time spent preparing records, responding to subpoenas and more.  If legal involvement evolves, the Center will provide you with our fee disclosure form.  These are non-negotiable.  
 

TESTIMONY for Divorce, Custody, and Visitation/Parental Access 

Main Line Therapy. LLC - DBA Main Line Play Therapy does NOT participate in custody hearings, custody/access disputes, vistation, or divorce proceedings.  These matters are not within our scope of practice.  Please contact a Parent Coordinator or another neutral party to assist you in this matter.  I have an excellent referral source should you need forensic mental health assistance.
 

FEES for FORMS AND LETTERS REQUESTS - From time to time, letters are requested for disability, schools, court, parenting coordinators or other such needs.  A checklist form provided by you is assessed at $50.  Any prepared letters requiring narratives for other purposes are assessed at $150 per letter for up to 2 pages. There is an additional fee for greater than 2 pages.   For more detailed assessments, please contact us at 610-642-1144 or email me

 

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