We are committed to

providing you and your

family with individualized

and compassionate care.

 

African American Mother with Daughter
Family Having Fun

Appointment Request Forms

 

To ensure we schedule your child with the appropriate provider, we require the forms below to be completed prior to scheduling an appointment.
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1. Patient Demographics & Health History - Katy
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 - admin@katychildpsychology.com

Fax - 713-264-8607 

Or you may also drop them off at our office location:
21384 Provincial Blvd. Katy TX 77450

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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

Other Forms

To save time at check in these additional forms can be completed and brought to the initial appointment.

HIPAA Privacy

Release of Information


**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.

 




Cancellation Policy

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.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.

Schedule Appointment

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