Thank you for choosing my counseling services .
I recognize you have many choices and I appreciate your trust in me.
Helpful Reminders For Your Initial Visit
EAP (Employee Assistance Program) Only Clients
- EAP clients obtain authorization /case number from your EAP Dept.
I will email all EAP client forms to you directly prior to your initial visit.
All Other Clients
- Obtain precertification / authorization number from health plan if required
- Print and complete the following items: Treatment Consent Form, Patient Registration Form and Intake Form as indicated below.
NEW CLIENT FORMS
I. Please print and complete the following 2 forms
( Per Patient)
If you are seeking treatment for your Minor Child(ren), please complete the additional consent form below for EACH child to be seen for counseling. If your minor child is named in a custody agreement or court order, please provide a current copy of the custody agreement or court order, as well as any applicable divorce decree prior to the commencement of counseling services - Texas Administrative Code 681.41 (aa).
II. Please complete the appropriate Intake Form
( Please Select Only One Per Patient Below As Applicable )
III. Payment Options
For Your Convenience, I accept Visa /Master Card, Personal Checks or Cash
TO PAY BY MASTERCARD / VISA PLEASE COMPLETE FORM BELOW:
TO PAY BY PERSONAL CHECK: PLEASE PAY TO THE ORDER OF Deborah Kabrane
TO PAY BY CASH:Cash receipt made available upon request
DEBORAH KABRANE, MA, LPC
555 Republic Drive, Suite # 200
Plano, TX 75074
Office: 972-422-9194 Fax: 972-422-9195
Business Cell: 214-605-5801
In response to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, the United States Department of Health and Human Services published a regulation in the form of the Privacy Rule. For the fulfillment of these requirements, I have provided the information below.
( HIPPA -Rev.2009 / 2014 )