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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

New Patient Forms

** Update: 12/01/2020 

Dear KCPA parents, 

We are continually reassessing risk to Covid19 exposure and updating our procedures as warranted.

Due to a recent increase in positivity rate in our area we are temporarily limiting in person visits to established clients only.

Exceptions will be made on a case by case basis or for diagnostic testing appointments.

We appreciate your cooperation and patience as we do our best to protect the wellness and safety of our clients and staff.

Thank you ~ KCPA Staff**

Help us better understand which provider can best meet your child's needs.

 New Patient Forms must be submitted prior to scheduling an appointment. 

Before completing, please also visit our provider page and insurance & rates page to learn more about the specific services that each of our professionals offers.

Click HERE to Complete & submit NEW PATIENT FORMS Online 

(ALL initial visits will be telemedicine video conference)

Please allow 15 minutes to complete these forms. 

 

Alternate Print Option - (If you've completed the online version above you do not need to do these)

You may also complete the forms by printing and emailing or faxing them.

1. Patient Demographics & Health History  (print version)

HIPAA Privacy (online form)

Release of Information (online form)

(All new patients or returning patients who were seen more than 6 months ago)
2. Parent Vanderbilt Questionnaire. (print version)

(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. **Please note: Due to technical limitations of working remotely, if I do not answer and you do not get a voicemail please call back. If I am on the phone with another client, phone calls are not automatically being directed to voicemail. Thank you for your patience. ~Nathalie**

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     

        Elizabeth Forman MA, LPC-Associate               Counseling/Therapies         Self Pay only

                                    Supervised by Courtney Suddath     

    Sarah Joyner MA, LPC-Associate, NCC    Counseling/Therapies             Self-Pay only

                                    Supervised by Courtney Suddath                     


 

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

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