Send an email to drroher@gmail.com
Contact
I do not provide direct billing for any Health Insurance, with the exception of Mayo Medical Plan - Mayo Premier Arizona.
Please contact your Insurance carrier if you need to know their reimbursement policy for out of network services. You are expected to pay at time of service. You will be provided with a SUPERBILL you can privately submit to your Health Insurance for possible reimbursement.
I am not a provider for MEDICARE.
My fees and HIPAA rules and regulations are stated in the "Informed Consent for Psychotherapy Services" and in the "HIPAA Notice of Privacy Practices" forms you will find listed below.
All clinical services are held virtually, using a HIPAA-compliant ZOOM platform. New patients are accepted for individual and couple Tele psychotherapy and Tele counseling services.
Please contact me to discuss any question you might have and to schedule an appointment at (480) 229-6666.
Forms
*Please complete and sign all the forms pertinent to the kind of services - individual or couple psychotherapy - you are seeking. If you are a couple, each of you should fill out all the forms for couple psychotherapy separately from the other. Once done, please email the completed and signed forms to me at drroher@gmail.com as attachments in a PDF format. Make sure I receive them before our first appointment. Thank you.
Collateral Agreement This agreement Form should be signed by a patient's family member, friend, or partner, invited to join treatment as collateral to the treatment. The purpose of this participation is to enhance the patient's treatment. As collateral, this person helps in the therapeutic process but does not become a patient him/herself. The rights and limits of this position are spelled out in this form. Please print and sign this form if this reflects your situation, and return it to Dr. Roher prior to the first session.
Forms required for Individual Psychotherapy
Informed Consent for Psychotherapy Services, Office Policies & General Information
HIPAA Notice of Privacy Practices
Individual Biographical Information
Patient's Medication List
Informed Consent Teletherapy Treatment Using Teletherapy Services
Patient's Health Questionnaire
Notice of Good Faith Estimate
Credit Card Payment Authorization
Authorization to Disclose or Obtain PHI
Treatment Agreement
Forms required for Couple Psychotherapy
Informed Consent for Psychotherapy Services, Office Policies & General Information
HIPAA Notice of Privacy Practices
Informed Consent for Patients in Couple's Therapy
Couple's Biographical Information
Relationship History
Couples CAQ Questionnaire
Patient's Medication List
Informed Consent Teletherapy Treatment Using Teletherapy Services
Patient's Health Questionnaire
Notice of Good Faith Estimate
Credit Card Payment Authorization
Authorization to Disclose or Obtain PHI
Treatment Agreement