Please complete and submit this form once your appointment is booked and confirmed:
Please provide payment at the end of each session/ evaluation. An invoice will be provided with the proper diagnoses and procedure codes to submit to your insurance company/HSA.
Fee Schedule: Check, cash, credit card
Per hour psychotherapy $175
School Visit $325
24-hour cancellation policy : Notwithstanding an emergency or illness, if you cancel an appointment within a 24 hour period, the full fee for the missed appointment will be billed. To cancel, please call Dr. Blum-410-371-3371 or Bonnie-410-4097139.
By printing and signing below, you are acknowledging receipt of the Privacy Act and agreement with the policies and fees described above.
Sign Here: _____________________________ Date: ____________________________