Please enable JavaScript in your browser to complete this form.Client Name *FirstLastSession Date *Session Time *Diagnosis Code *CPT CODE *90837 – Psychotherapy 60 mins with patient90837 95- Psychotherapy 60 mins VIDEO session90839 – Psychotherapy with Crisis 60 mins90840- Crisis add on (each additional 30 mins)99050- Add on code for sessions before 9 AM and after 5 PM and weekend sessions90853 – Group TherapyOther CPT Code – indicate in comment sectionFollow Up Appointment Scheduled Date and TimeCommentsCounselor's E-Sign *Type initials for E-signature WebsiteSubmit
