Paul Roy

Paul Roy, LCSW

Therapist / Licensed Clinical Social Worker
(303) 981-5586E-mailMap

The following form is required prior to your first session.

Initial Intake Form

Today's Date
Name
E-Mail
Date of Birth
State ID #
Street Address
City / State / Zip
Client Name
Relationship to client
Client Name
Relationship to client
Client Name
Relationship to client
Home Phone
OK to leave a message?
Cell Phone
OK to leave a message?
Work Phone
OK to leave a message?
Place of Employment
Refered by

In Case of Emergency Contact:

Emergency Contact
Relationship
Phone
Primary Care Physician
Phone

Person Responsible for Payment:

Who is responsible for payment?
Relationship
Address
Phone
Date of Birth

Insurance Information:

Insurance
Phone
Group #
Address for Claims
Name of Insured
Date of Birth
Authorization #
# of Sessions Authorized
Co-pay
Deductible

Payment is expected at the beginning of each session. I am a participating provider with Anthem Blue Cross Blue Shield, CIGNA, and Medicaid from Denver, Arapahoe, and Douglas Counties, and will accept co-payments and bill your insurance for reimbursement. Covered benefits are not a guarantee of payment to me and you will be responsible for any service denied by your plan. If you are planning to use any other type of insurance to pay for your services, I will assist you in determining coverage, benefits and eligibility, but you are expected to pay the full fee at the time of your visit and to file your own claims. Most insurance plans do not cover marital therapy or couples counseling, but I will be happy to provide you with an invoice for your own submission efforts.

My fee is $120 per session and I accept cash, checks, or major credit cards. I offer a sliding fee for those with no insurance or limited income. I will discuss this on a case-by-case basis with each client in order to reach a mutual fee agreement. Clients are asked to give 24 hours advance notice when canceling an appointment. I charge an $80 cancellation fee to clients who cancel without notice, and insurance companies will not cover these fees. Exceptions may apply for true emergencies.

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Paul Roy, LCSW
Therapist / Licensed Clinical Social Worker

2750 S Wadsworth Blvd.
Suite D-103
Denver, CO 80227
303-981-5586