New Clients

Y ou should be commended for taking a step toward seeking psychological services from a well-trained, licensed psychologist. Making the decision to seek psychotherapy services is a sound and potentially life-changing decision.
We are invested in helping you make changes that may allow you to live a more satisfying, healthy, and well-balanced life.

Please continue your journey to wellness by contacting us to make an appointment with either Dr. Brian Selby or
Dr. Christine Selby.

Below you will find sections on 1) Fees and Insurance, 2) Printable Forms (including the Outpatient Services Contract From which includes a complete description of our policies and procedures) and 3) HIPAA and Federal Red Flag
Rules.

FEES insurance

Payment is expected at the time services are provided. The full fee is due at the time of your appointment. If however, you are using insurance you may only be responsible for a co-payment or coinsurance amount.

If you are using insurance pre-authorization may be required. Please verify with your insurance company what your behavioral health benefits are.

Fees

Initial 45-50 minute appointment (diagnostic interview): $165.00
Ongoing 45-50 minute sessions: $110.00 per session.
Crisis Sessions: $150.00

Insurance

Please see the information on the far left to see if Dr. Selby accepts your insurance. If your insurance is listed it will be important for you to verify with your insurance company details on deductibles, coinsurance, and co-payments. You may have to pay the entire session fee if you have a deductible.

If your insurance is not listed you may still be able to use your "Out of Network" benefits. We recommend contacting your insurance company regarding this option.

For additional questions about billing, payment, or insurance please send an email to DrChristineSelby@Hushmail.com or call 207-299-2552 to leave a message

Payment

The following forms of payment are currently accepted:

Cash
Personal Checks (in state only)
American Express
Discover
Master Card
Visa
Debit Cards

As an added convenience, you can authorize Dr. Selby to charge your Credit or Debit card for co-payments, deductible fees, etc. Please print and complete the Credit Card Authorization Form for this purpose.

PRINTABLE forms

Several forms are required to initiate services with Selby Psychological Services. To save time at your initial
appointment (or to avoid having to arrive early) please complete the forms below to bring with you to your first
meeting.

***Please Note: The Intake Paperwork Documents and the Credit Card Authorization Form (above) are fillable pdf files. In order to use the fillable form and signature features you will need the latest version of Acrobat Reader.

You will need to complete the first two forms: 1) Outpatient Services Contract and 2) Disclosure of
Health Information Consent Form (HIPAA). You will also need to complete either the Adult Intake Form (for clients 18 years old or older) or the Child Intake Form (for clients 17 years old or younger). The Release of Information Form can be printed in the event that there are family members and/or other professionals with whom you would like Dr. Selby to communicate or coordinate services.

Outpatient Services Contract

Disclosure of Health Information Consent Form (HIPAA)

Adult Intake Form

Child Intake Form

Release of Information Form

Telehealth Informed Consent

HIPAA federal red flag rules

Selby Psychological Services strictly adheres to the Health Insurance Portability and Accountability Act
(HIPAA). As such we have developed a HIPAA Policy Statement.

We also adhere to the Federal Trade Commission's "Red Flag Rules"which require us by Federal Law to ensure
that the individual seeking services is also the individual named in the insurance policy. To accomplish this, we will
ask you to bring photo identification (i.e., driver's license, passport, or other government issued ID) and current
insurance card. If the address on your photo ID is not current then we will require a utility bill, lease or other evidence
of current address.