To ensure your child sees the appropriate provider,
the forms below must be submitted prior to scheduling an appointment.
(All new patients or returning patients who were seen more than 6 months ago)
(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 appointments 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. Every effort will be made to contact you the same day, or the next business day after receiving the completed forms.
Office Admin hours are: Mon-Fri 11am-5pm
Dr. James Poysky PhD, Clinical Psychologist/Neuropsychologist Evaluations Aetna, Cigna, SelfPay
Alyssa Muchaw MA, LPC, NCC Counseling/Therapies Self Pay only
Kevin Dailey MEd, LPC- Intern, NCC Supervised by Brett Bergvall Counseling/Therapies Self Pay only
To save time at check in these additional forms may be completed and brought to the initial appointment.
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
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.
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.
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.