Patient Registration
Help us get to know you better so we can provide the best care possible.
REQUIRED FORMS
New and returning patients are required to complete these forms
prior to your first appointment.
New and returning patients are required to complete these forms prior to your first appointment.
Consent & Release Form
Secure your privacy and authorize care with our digital consent forms.
HIPPA Acknowledgement
Ensuring your health information remains secure and confidential.
Insurance Verification Form
Ensuring you get the most out of your coverage from
day one.
Medication Consent Form
Essential information regarding your treatment plan and prescriptions.
Patient Intake Sheet Form
Complete your intake securely to begin your path to
wellness.
Payment Agreement Form
Clear information regarding our billing, insurance, and payment policies.
Policies & Procedures Form
Our commitment to your care, privacy, and professional standards.
TelePsych Consent Form
Simple authorization for your secure virtual therapy
sessions.
Testimonials
Frequently Asked Questions
Accepted Insurance Plans
We proudly accept the following providers:
▪ Medicare
▪ Aetna
▪ UBH/Optum (United Behavioral Health)
▪ Cigna
Important:
If you have Medicare or a Medicare Advantage Plan, we recommend calling the customer service number on your insurance card to confirm your mental health benefits and ensure our services are covered.
Please Note:
Patients are responsible for any costs not covered by insurance, including co-pays, deductibles, and any non-covered services.
Self-Pay Rates
No insurance? No problem. We offer simple, competitive pricing:
Initial Psychiatric Evaluation – $200
A comprehensive first visit including full assessment and personalized care planning.
Follow-Up Appointments – $125 per visit
Typically 10–30 minutes, tailored to your needs.
One-Time Visit (Non-Member) – $150
Ideal for consultations or second opinions without ongoing care.
Membership Plan (Optional)
For regular care at reduced rates:
▪ Monthly Fee:$120
▪ Discounted rates on all visits
▪ Priority scheduling
▪ Direct access to your provider
Minimum 3-month commitment required.
Interested in enrolling? Just let us know!
Missed Appointment / Late Cancellation Policy
To respect your provider’s time and ensure availability:
▪ $50 fee for missed or late-cancelled 60-minute sessions
▪ $25 fee for missed or late-cancelled 30-minute sessions
Cancellations made with less than 24 hours’ notice or missed appointments will incur a fee.
These charges are not covered by insurance and will be billed directly to you.
Begin Your Path to Wellness.
Catherine Mepukori PMHNP-BC
Nurse practitioner PMHNP-BC
MSN
Board-Certified Psychiatric Nurse Practitioner
