To ensure we schedule your child with the appropriate provider, we require the forms below to be completed prior to scheduling an appointment.
1. Patient Demographics & Health History
2. Parent Vanderbilt Questionnaire. (New patients 5 years or older)
Print to complete, or open with Adobe Acrobat Reader to complete. Download Adobe Acrobat Reader for free, click here.
3. Send a copy of the front and back of the insurance card (if it is to be billed).
(For evaluation appointments with Dr. Poysky or Dr. Lyle-Lahroud only. Therapy/Counseling service providers are not in-network with insurances.)
Please return forms by:
Email - email@example.com
Fax - 713-264-8607
Or you may also drop them off at our office location:
21384 Provincial Blvd. Katy TX 77450
Dr. James Poysky Alyssa Muchaw LPC-Intern, NCC
Aetna, BCBS, Cigna Not in-network with Insurance
Self Pay Self Pay only
Please contact Nathalie or Shay, at 281-829-1599 with any questions or concerns about completing these forms.
We will make every effort to call you to schedule an appointment within 24-48 business hours after receiving the completed forms. Office Administration hours: Mon-Fri 11am-5pm
To save time at check in these additional forms can be completed and brought to the initial appointment.
**Please note these important factors:
KCPA is a small private practice with limited time and resources.
We will check benefits only 1 or 2 days prior to the scheduled visit date.
We encourage you to verify the following information for your child as soon as possible and well before the scheduled appointment, so you are aware of your benefit coverage.
Please call the member services department of your insurance carrier to get answers to these questions:
1. Does my child have mental health benefits? (If no, please call us to verify office visit charges)
2. Will mental health benefits be billed directly to Cigna, BCBS, or Aetna? (If no, KCPA will not bill to any other payor. Please call us to verify out of network visit charges)
3. Is there a remaining deductible balance that needs to be met? What percentage is covered after that is met?
4. Is there an office visit copay?
5. Will a testing visit CPT code 96101 be covered under a copay or deductible?
Visits that are not billed to insurance can be paid with cash, check or major credit card and are due at the time of the visit.
Failure to show for your scheduled therapy or testing appointment, without at least 24 hours advance notice, will result in late cancelation/no-show fee of $50 per standard (1-hour) appointment, and $250 fee for each and any testing (2 or more hours) appointment.