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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 your child sees the appropriate provider, 

the forms below must be submitted prior to scheduling an appointment.

1. Patient Demographics & Health History   

(All new patients or returning patients who were seen more than 6 months ago)


2. Parent Vanderbilt Questionnaire. 

(New patients 5 years or older, or patients who were seen more than 6 months ago)

Print to complete, or open with Adobe Acrobat Reader to complete. Download Adobe Acrobat Reader for free, click here


3. Copy of the front and back of the insurance card.                                                                                                          For appointment requests with Dr. Poysky only Aetna or Cigna.  All others are out-of-network)

Please return forms by:

Email - [email protected] 

Fax - 713-264-8607 

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

Please contact Nathalie at 281-829-1599 with any questions or concerns about completing these forms. We will make every effort to contact you the same day, or the next business day after receiving the completed forms.   Office Administration hours: Mon-Fri 11am-5pm

                                                                                                  

     Dr. James Poysky                                                                                     Alyssa Muchaw LPC-Intern, NCC

     Evaluations                                                                                                Counseling/Therapies

     Aetna,  Cigna,                                                                                            Not in-network with Insurance

     SelfPay                                                                                                       Self Pay only

     

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Other Forms

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

HIPAA Privacy

Release of Information


Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
Privacy Policy

Release of Information

Katy Child Psychology Associates recognizes the important role primary care physicians, other health care providers or school professionals play in the care of your child.
KCPA will only share information with these providers with your permission and require a completed and signed Release of Information for each provider.

 



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

We would love to meet you and your child!

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