Please complete and submit this form once your appointment is booked and confirmed: 

Name of Client *
Name of Client
Address
Address

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

Evaluation $2,500

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: ____________________________