Please be advised that there is an initial program fee of $175.00.  The program fee is for online education and resources, specialized evalution of eating, body and weight and lifestyle issues and an individualized recovery program.  If you have insurance,  those benefits may be applied to subsequent sessions.

We appreciate your business and look forward to working with you.

you're a new client, please complete the following forms and bring them to your first session.

Consent to Release
Beth's Disclosure and Consent Form
Lisa's Disclosure and Consent Form
New Client Intake Form

Note: To download Adobe Acrobat Reader for free, click here.

 

Please Print Out and Bring With You to First Appointment

                                       Riley Therapy

                            Beth N. Riley, MSW, LISW-CP

                             Lisa A. Shohen, M.A., LPCI

                                     710 Pettigru Street

                                   Greenville, SC 29601

                                        864-787-1946

                                 Fax: 864-241-9001 

 

Insurance Company The Employer’s Name

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Name of Insured (as it reads on card) DOB for Name Insured

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Group Number Plan Code

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SS# for Name Insured Effective Date of Policy

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Insurance Mailing Address

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Mailing Address for Claims (if different from above)

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Insurance Phone Number for Providers

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I understand that any portion of Beth Riley’s or Lisa Shohen’s fee not covered by the insurance information listed above is my responsibility and due in full at the first session.

After the initial program fee,  some insurance companies will pay a portion of your entire bill. This varies greatly from plan to plan.   You must check your policy or contact your company if you wish to know if your plan covers my services. If you are under managed care, you must first call the company for referral or pre-authorization. If your insurance company only authorizes a certain number of sessions,  it is the client's responsibility to remind the therapist to apply for more sessions. If the client fails to remind the therapist about applying for more sessions, the patient is reponsible for the amount owed the therapist for any denied visits. If I am not on your panel of providers, you may still have out of network benefits. I can provide you with the necessary paperwork to file with your insurance. 

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Your Name in Full Today’s Date

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Signature