This appointment is for cash patients FU appointments only. Please read the instructions for this schedule before confirming your appointment.

This appointment is for a medication refill only. Please read instructions before confirming your appointment.

• The booking fee ($55) is refundable if your insurance does not require a deductible.
• If your co-pay is less than the booking fee, the difference will be refunded to you.
• If your booking fee does not fully cover your session cost, you must pay the remaining balance before your session begins.

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Please read to confirm you are paying out of pocket for this visit.
This is the first appointment visit

Insurance Patient Booking Fee Policy

• The booking fee ($55) is refundable if your insurance does not require a deductible.
• If your co-pay is less than the booking fee, the difference will be refunded to you.
• If your booking fee does not fully cover your session cost, you must pay the remaining balance before your session begins.

**Casting Crown Psychiatry Services, PLLC – FMLA Form Completion Policy**  
**Effective Date:** 3/13/15  
**Last Updated:** 3/13/25 

This Policy is an agreement between Casting Crown Psychiatry Services, PLLC ("the Practice") and you ("Client"). By paying for FMLA form completion services, you confirm that you have read and agree to this Policy.

1. **Eligibility**  
   To request FMLA form completion, you must:  
   - Be an established patient at Casting Crown Psychiatry Services.  
   - Have completed at least three (3) visits with a provider at the Practice.

2. **No Employer Approval Guarantee**  
   We do not guarantee that your employer will approve your FMLA request, as this is solely at their discretion.

3. **No Legal Representation**  
   We do not provide legal advice or representation related to FMLA matters. Please seek your own legal counsel if needed.

4. **Fees**  
   - Completion fees exclude legal or employment-related services.  
   - Phone calls on your behalf will incur a minimum fee of $40 per call.  
   - Standard turnaround time for form completion is seven (7) business days. For completion within 24 hours, an additional fee of $100 applies.

5. **Agreement**  
   By proceeding with payment, you agree to:  
   - Accept this Policy and its terms.  
   - Understand associated fees and that we do not guarantee employer approval.  
   - Acknowledge that no legal representation is provided.   

By submitting payment, you know you have read and agree to this Policy.

**Casting Crown Psychiatry Services, PLLC – ADA/Short-Term Disability Form Completion Policy**  
**Effective Date:** March 13, 2025  
**Last Updated:** March 13, 2025  

This Policy establishes a binding agreement between Casting Crown Psychiatry Services, PLLC ("the Practice") and you, the patient ("Client" or "You"). By paying for ADA (Americans with Disabilities Act) and/or Short-Term Disability form completion services, you confirm that you have read and understood this Policy.

**1. Establishing Care Requirement**  
To request form completion, you must:  
- Be an established patient with at least three (3) visits at the Practice.

**2. No Guarantee of Approval**  
We do not guarantee approval from your employer, insurance company, or any third party for your ADA or Short-Term Disability request, as these decisions are beyond our control.

**3. No Legal Representation**  
We do not provide legal advice or representation regarding ADA or Short-Term Disability matters. Seek legal counsel independently if needed.

**4. Fees and Payment Terms**  
- Payment covers only the completion of forms, not additional legal or employment services.  
- **Phone Calls:** $40 per call on your behalf.  
- **Turnaround Time:** Standard completion time is seven (7) business days; expedited completion within 24 hours incurs an additional $100 fee.

**5. Acknowledgment and Agreement**  
By proceeding with payment, you agree to:  
- Accept this Policy.  
- Understand the fees for services.  
- Acknowledge that approval from your employer or insurer is not guaranteed.  
- Recognize that no legal representation is provided.

Submitting payment indicates your acceptance of this Policy, forming a legally binding contract with Casting Crown Psychiatry Services, PLLC.

Follow-up individual Psychotherapy. This payment is for cash-paying patients only.

Follow-up Couples Therapy. This schedule is for cash-paying patients only.

Initial Couples Psychotherapy

Insurance Patient Booking Fee Policy

• The booking fee ($55) is refundable if your insurance does not require a deductible.
• If your co-pay is less than the booking fee, the difference will be refunded to you.
• If your booking fee does not fully cover your session cost, you must pay the remaining balance before your session begins.

Individual Psychotherapy first visit. This visit is for cash paying only.