Information & Forms | Regal Oak Counseling, LLC

Info & Forms

intake & assessment

New Clients

Each new client registers online or in our office and is scheduled for an initial intake and assessment. This initial intake appointment allows the therapist to review information, explain the process, ask and answer questions, and determine a treatment plan that meets your individual needs. If you have questions or concerns, this is a great time to ask your therapist. We recommend making a list of your questions and concerns to bring to your intake appointment.

Prior to the intake appointment:

Please email a copy of the following documents to register@regaloakcounseling.com

For Adults:

drivers license

insurance card (front and back)

For Minors (Under 18 years of age):

drivers license of parent or legal guardian

insurance card (front and back)

full copy of divorce decree AND custody documents, if applicable (Texas State Requirement)

Please bring all documents to your initial visit

You may also need to bring a list of any current medications and supplements,
name and contact information of healthcare providers (primary doctor, psychiatrist, specialists, etc.), discharge paperwork, psychological testing and assessment reports you would like to share with your counselor

Important:

We require your arrival 30 minutes prior to your scheduled intake appointment to allow time to complete intake paperwork

Please note: The online registration does NOT replace intake paperwork/consent for treatment required by the State

Minors must be accompanied by their parent or legal guardian for the initial appointment.

The person completing paperwork for a minor MUST BE LEGALLY AUTHORIZED to sign for their psychological care

Minors may NOT be left on the premises at any time while attending a counseling session.

Minor children under the age of 13 years old may not be left in the waiting room unattended, no exceptions.

If you have scheduled a telehealth/online appointment:

Your intake paperwork/consent for treatment will be sent to you via email.

Please email the documents listed above to register@regaloakcounseling.com

Once we receive your intake paperwork and documents, we will text or email you a link to connect with your counselor via a secure HIPAA compliant platform for your session.
Your appointment will be rescheduled if the appropriate paperwork is not provided prior to the date of your appointment

For all sessions following your initial appointment:

Please present your drivers license and insurane card at time of check in for each appointment

Late Arrival:

If you arrive less than 20 minutes prior to an initial appointment your appointment will be rescheduled.

If you arrive more than 10 minutes late for any subsequent appointment, please expect to be rescheduled.

Good Faith Estimate

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 call 817-281-6822.

Important Information

Location

Regal Oak Counseling is located at 1285 N. Main St. #101, Mansfield, TX 76063, Phone (682) 651-7621

(One block north of Legacy Mansfield High School in the tan building with green awnings)
Forms
Some of the information you will be asked to provide may include:
- Registration Forms and Consent for Treatment
- Release of Information, if applicable
- Notice of Privacy Practices
Prior to your first visit, we encourage you to complete the intake paperwork and consent for treatment. This paperwork may have been emailed to you in advance. It may also be downloaded from the link below. Otherwise, please arrive at least 30 minutes prior to your scheduled appointment to allow time for paperwork completion.

Links to printable forms (click to download):
New Client Paperwork Packet
Release of Information
Privacy Practices
Exception Authorization
Privacy Practices

We value your privacy. Detailed information about privacy, including limitations, is provided during intake and assessment. To print or view a copy of our Notice of Privacy Practices, click here
Payment & Insurance

As of March 18, 2024, we accept AETNA, BCBS, Cigna/Evernorth, Optum/United Healthcare, Carelon, Traditional Medicaid, Wellpoint/Amerigroup, and Aetna Better Help. We are currently waiting to get in network with Medicare and TriCare. This takes time but is in process. If you choose not to use your insurance for your care, a superbill is available upon request to submit for reimbursement for your insurance. However, you should know that filing any kind of claim with your insurance company requires your counselor to provide a mental health diagnosis. Diagnoses, for adults and children, become part of your medical record.

You should also know that web and phone counseling (teletherapy/telehealth) are covered by some insurance policies, but not all.

NOTICE: We cannot guarantee what your insurance will/will not reimburse for services.

Payment for services are due in full at the time of service*. We accept Visa, MasterCard, Discover, American Express, HSA cards, CareCredit and cash. A superbill is available upon request.
Fees

Private pay rates range from $95 - $165 depending on the session type, length of session, and whether you are seeing a Masters level or PhD level Licensed Professional Counselor. Fees for peak performance sessions begin at $165.

The fee for cancellation less than 24 hours prior to your appointment time is $35. Fees for no call/no show are the full session rate.

For executive and discretion service rates please contact our office and ask for Dr. Allen.
Cancellation Policy

We value your time and do our very best to prevent schedule delays and cancellations. If you are unable to make a scheduled appointment, we ask that you notify our office VIA TELEPHONE a minimum of 24 hours in advance so the appointment time may be made available to others. You can leave a voicemail, but please do NOT send an email to cancel as we may not receive it in time to prevent charging your account.

Same-day cancellations (less than 24 hours notice) are charged $35, and no call/no-show appointments are charged full appointment rate, emergencies notwithstanding.

If you have unusual circumstances (Military, Public Service, etc) please let us know at the time of registration.