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4100 McEwen
Suite 285
Farmers Branch, TX 75244
Phone: 972-820-9965
Fax: 866-278-4727

  
 
 
Monique Thompson, LPC & Associates
Pre-Register

NEW PATIENT PRE-REGISTRATION - PART A (Fees & Office Policy)


All fees for counseling are due at each session.  Appointments for additional sessions cannot be made until your balance is paid in full or other payment arrangements have been made.

 

You are responsible for any appointments that are not canceled at least 24 hours prior to your appointment time, with the exception of an emergency.  The fee for calling the day of your appointment is $45.00.  The fee for not showing up for an appointment is $50.00.

 

If a check is returned, a processing fee of $25.00 will be assessed to your account.  Additionally, the client will need to make a cash or money order payment for the amount of the returned check and the $25.00 processing fee.  This office may require cash payment of future appointments after a returned check.

 

Fees are:

 

$50.00 per 30 -35 minute appointment

$100 per 50 minute appointment

                    $65/50 minute appointment paid 5 appts at a time

                    $80/50 minute appointment paid 2 appts at a time
  • Late cancel (calling the day of your appointment) $45
  • No Show (not calling and not showing up for your appointment) $50
  • Testing fees $50/per test

 

 

Payments Accepted

Cash & Personal Checks, MasterCard, Visa and Discover


*Note your fee schedule may vary depending on the counselor with whom you are scheduled to meet.  Notably, appointments with Katie Khuc, LPCI, Kimberly Brady, LPCI and Cindy McCartney, LPCI are likely to cost less than the fees for appointments with Monique Thompson, LPC

 

Your New Patient Code is provided in the welcome email from your counselor after scheduling your first appointment.
New Patient Pre-Registration

You will need your NEW PATIENT CODE to complete this pre-registration form. Please email admin@northdallascounselor.com or call 972-820-9965 x 1 if you have questions about completing this form or scheduling your first visit.
I have read, understand and agree to the payment information as stated above  yesno                 
New Patient First and Last Name:
(if minor) New Patient Parent or Guardian First and Last Name:
New Patient Code:
I acknowledge that Therapist provided me with a written copy of his Notice of Privacy Practices.  yes no 
I have read, understand and agree to the office policies as stated above  yes no 
Finally, please enter your email address and thank you for completing your pre-registration:
Copyright . Monique Thompson, LPC. All rights reserved.
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