Forms for New Clients
All new clients must complete the teen or adult information sheet as well as the "Consent for Treatment" form. If you'd like me to collaborate with or talk to another professional, such as a psychiatrist or guidance counselor, please complete the "Release of Information Form" as well.
All files can be downloaded and completed electronically, then printed and brought to your first appointment or sent via email to Amy Fantalis or Wendi Haldeman prior to the session.
| Consent for Treatment |
| Teen Information Form |
| Release of Information |
| Confidentiality Agreement |
Fees & Insurance
Hourly fees for individual appointments range between $130-$175/session, depending on the therapist. We sometimes work on a sliding scale and welcome discussion if you need a fee reduction. The fee for group is $85 per weekly session.
Our practice is fee for service and we do not participate with insurance companies. However we are able to provide monthly or as needed receipts for submission to your insurance company. If you have out of network benefits and have met your deductible, you may be eligible for some reimbursement. We suggest that you contact your insurance company to research this further.
We accept cash, checks or credit cards as payment. Our preferred method of payment is by check. Payment is appreciated at each session.
Our practice is fee for service and we do not participate with insurance companies. However we are able to provide monthly or as needed receipts for submission to your insurance company. If you have out of network benefits and have met your deductible, you may be eligible for some reimbursement. We suggest that you contact your insurance company to research this further.
We accept cash, checks or credit cards as payment. Our preferred method of payment is by check. Payment is appreciated at each session.
cancellation policy
Kindly give a minimum of 24 hours notice when canceling an appointment to avoid being responsible for full payment of the session. If you give less than 24 hours notice and we can schedule your hour, we do not charge. Missed sessions are charged for in full.
My office is located in the heart of downtown Media, which is easily accessible by car, trolley and SEPTA regional rail train. We are in a residential community and parking is generally available in the front of our building. Please be aware not to park in the parking spots with an
R across the street, as they are Resident Parking spots and you will be ticketed.
From the north: Take the Blue Route (476) South to Exit 5 and make a right at the light at the end of the ramp. Merge onto Route 1 South but get off immediately at the very first exit, State Road. Come around the exit ramp and make a right onto State Road. Stay straight thru the first traffic light (Rte 252/Providence Road) and proceed for several stop signs down Monroe Street. Our office is located on the right side of Monroe St, between 2nd & 3rd Streets.
From the south: Take the Blue Route (476) to Exit 3, Media/Swarthmore. At end of exit ramp, make a left onto Baltimore Pike. Follow Baltimore Pike approx 6 traffic lights (approx 1 mile) and make a right onto Monroe St. We are a few blocks up on the left between 2nd & 3rd Streets.
By trolley: take the 101 trolley to Media and ask to get off on the corner of Monroe and State Streets. You will be near the Media Theatre and Media Elementary School. Walk two blocks up Monroe St and we are on the left between 2nd & 3rd Streets.
By SEPTA train: Take the Media/Elwyn train to either Moylan Rose Valley or Media. Each stop is approx 1 mile from the office.
If you get off at Moylan Rose Valley, walk north on Manchester Ave til you reach State St. Turn left onto State St and walk a few blocks up to Monroe St. Make a right onto Monroe and we are located on the left between 2nd & 3rd Streets.
From the Media stop, walk up the hill on Orange St until you reach State ST. Make a right onto State St and walk down to Jackson ST. At Jackson, make a left and walk up two blocks to 2nd Street. Make a right onto Monroe St and we are on the left side bt 2nd & 3rd Sts.
R across the street, as they are Resident Parking spots and you will be ticketed.
From the north: Take the Blue Route (476) South to Exit 5 and make a right at the light at the end of the ramp. Merge onto Route 1 South but get off immediately at the very first exit, State Road. Come around the exit ramp and make a right onto State Road. Stay straight thru the first traffic light (Rte 252/Providence Road) and proceed for several stop signs down Monroe Street. Our office is located on the right side of Monroe St, between 2nd & 3rd Streets.
From the south: Take the Blue Route (476) to Exit 3, Media/Swarthmore. At end of exit ramp, make a left onto Baltimore Pike. Follow Baltimore Pike approx 6 traffic lights (approx 1 mile) and make a right onto Monroe St. We are a few blocks up on the left between 2nd & 3rd Streets.
By trolley: take the 101 trolley to Media and ask to get off on the corner of Monroe and State Streets. You will be near the Media Theatre and Media Elementary School. Walk two blocks up Monroe St and we are on the left between 2nd & 3rd Streets.
By SEPTA train: Take the Media/Elwyn train to either Moylan Rose Valley or Media. Each stop is approx 1 mile from the office.
If you get off at Moylan Rose Valley, walk north on Manchester Ave til you reach State St. Turn left onto State St and walk a few blocks up to Monroe St. Make a right onto Monroe and we are located on the left between 2nd & 3rd Streets.
From the Media stop, walk up the hill on Orange St until you reach State ST. Make a right onto State St and walk down to Jackson ST. At Jackson, make a left and walk up two blocks to 2nd Street. Make a right onto Monroe St and we are on the left side bt 2nd & 3rd Sts.
