Kathryn F Hecht PhD, LP

Name *

First Name

Last Name

Phone *

(###)

###

####

Main area(s) of concern: *

Worry about specific people, places, things or situations

Unwanted thoughts and/or rumination

Obsessions and/or compulsive behavior

Perfectionism

Panic attacks

Sleep Problems

Difficulty with social situations

Picky or restrictive eating

Low mood or depression

Skin picking and/or hair pulling

Oppositionality or defiant behavior

Distractability or problems with focus

Refusal to go to school

Safety concerns such as self-injury, aggression or suicidal thoughts

Other

Are you open to working with a student clinician being supervised by Dr. Hecht?

Yes

No

GFE Notice: You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059. *

I have reviewed the above information and understand my right to receive a Good Faith Estimate.