Forms and Policies

If you are a new client, please print and complete these forms and bring them to your first session. If you do not have access to this paperwork, please let me know during our initial phone call and I will mail you hard copies.

Click on the links below to download forms:

All new clients:
New Client Information
Information Release
Disclosure Statement
Disclosure Receipt
HIPPA Receipt
Edinburgh Postnatal Depression Scale

For coaching clients only:

Policies- Kate Kripke, LCSW

1. Fee Related Policies

Fees: Please contact me to discuss my current fees.  My fees are typically for 50 minute sessions although we can schedule longer 90 minute sessions for an increased fee if/when needed.  I request payment at the time of service unless other arrangements with me have been made.  Payment is received in the form of cash, check, or major credit card.

Insurance: At this time, I have chosen not to join any health insurance panels.  However, if your health insurance carrier enables you to choose an “out -of-network” provider, you may be eligible to receive reimbursement for psychotherapy services from a Licensed Clinical Social Worker.  Upon request, I am able to provide a reimbursement receipt or “super bill” for submittal to your insurance company.  If you intend to use insurance, I recommend that you contact your plan to ask about your psychotherapy benefits and rates for reimbursement for out-of-network providers.  Please remember that my services are provided and charged to you, not your insurance company, so you are responsible for payment.

Commitment to Care: Based on my commitment to providing care to a diverse group of individuals, I do have limited availability of lower fee slots.  I encourage you to inquire about lower fees if you are in need of accommodation.

2. Telephone Availability and Emergencies

Telephone messages are typically returned during business hours.  I check my voice mail frequently and am committed to returning calls as soon as possible.  Although I am not in the office on Monday, Friday, or weekends, you are welcome to call my during these times, and I will do my best to return your call quickly.  Please note- I do not provide emergency services.  In an emergency situation, please dial 911. contact your primary care provider, or go to the nearest hospital emergency room.

3. Cancellation

Appointment scheduling involves the reservation of time especially for you, therefore, it is important to provide at least 24-hours cancellation notice by phone should you need to cancel or reschedule your appointment; otherwise the full fee will be charged and will be due at the time of your next appointment.  I certainly expect to do make exceptions to this policy for physical illness or anything else that can be reasonably called an “emergency.”