MODIFIED SERVICES DUE TO THE COVID-19 PANDEMIC

To protect your health and the health of our community, all visits have been converted to telehealth. For new clients interested in scheduling an appointment, please complete this form and email it to: michele@micheleadam.com. Once I have received the form, I will contact you within 5 business days to schedule an appointment or let you know that I am not able to meet your needs at this time.

PAYMENT & POLICIES

I accept the following commercial insurance plans, as well as private pay.

• Blue Cross Blue Shield
• Tufts Health Plan
• Optum (Harvard Pilgrim, Allways, United Behavioral Health)

Please contact your insurance carrier to verify your behavioral health coverage and find out if you have a deductible. If you do not have one of the above insurance plans, find out if you have benefits for out of network coverage. Payment is expected in full at the time of service. I accept Visa, Mastercard, Discover and FSA/HSA cards, as well as cash or check. Please provide at least 24 hours notice to cancel or reschedule an appointment. You will be charged for same-day cancellations or failure to show for your appointment.

FIRST APPOINTMENT

I provide psychiatric evaluations and on-going medication management for adult clients (18+). Until further notice all visits are taking place via teleheatlh. The first appointment, or psychiatric evaluation, lasts 60 minutes. It is important for me to understand your symptoms and struggles, as well as your strengths. We will review your history and begin to develop a treatment plan.

Please complete this form and email it to me at: michele@micheleadam.com before your first appointment, along with your insurance card and method of payment.

If you are unable to send this form by email, please have your form(s) as well as images of your insurance card available on your computer. We can transfer your documents through the conferencing software.