I AM NO LONGER TAKING NEW CLIENTS. Please see my Referral List for other providers.

(949) 858-6688

Mariam A. Mott, Ph.D.
Mariam A. Mott, Ph.D.
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    • Home
    • Services
    • About
    • FAQs
    • Contact
    • Fees/Forms
    • Resources
  • Home
  • Services
  • About
  • FAQs
  • Contact
  • Fees/Forms
  • Resources

Fees/Forms

Fees and Insurance

Assessments: Testing is priced on a "flat fee" basis depending on the referral question (see Assessment Agreements and Price List below). A minimum of 50% percent of the estimated cost is due at the first testing appointment, and the  remaining 50% is due upon receipt of the completed report. I accept checks, cash, or Zelle transfers as payment (I am not set up to accept debit or credit cards at this time).

Counseling/Therapy: $150.00 per 60-minute session (see Counseling Agreements below). Payment is due at the time of service unless other arrangements have been made in advance. I accept checks, cash, or Zelle transfers as payment (I am not set up to accept debit or credit cards at this time).

Insurance: I am a “fee for service” provider, which means that you are responsible for  payment. I will not bill your insurance company directly, but I will provide you with an invoice (Super Bill) that includes the necessary CPT codes, diagnostic codes, and NPI number that you can submit to your insurance company for reimbursement at the out-of-network rate. It is strongly recommended that you contact your insurance company in advance of your appointment to  determine whether they will cover services, and if so, under what  conditions. Please note that some insurance companies require  pre-authorization in order to provide any reimbursement for services provided. 

Cancellation Policy: Your appointment is a time set aside for you. If you are unable to  attend, you are expected to cancel as soon as possible and at least 24  hours in advance. Cancellation fees typically apply when appointments are cancelled with less than 24 hours notice. PLEASE NOTE: This policy is waived during the COVID-19 pandemic.

Forms

Downloadable Forms

Assessment Agreements (Youth) June 2020 (pdf)

Download

Counseling Agreements (Youth) June 2020 (pdf)

Download

Intake Form (Youth) December 2019 (pdf)

Download

Release of Information/Records May 2020 (pdf)

Download

Counseling Agreement (Adult) June 2020 (pdf)

Download

Referral List June 2018 (pdf)

Download

CV December 2023 (pdf)

Download

"The future starts today, not tomorrow."

--Saint Pope John Paul II

Copyright © 2024 Mariam A. Mott, Ph.D. - All Rights Reserved.


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Announcement

Unfortunately, I am not accepting new clients at this time due to my full-time employment with a nonprofit organization serving disadvantaged youth and families. Please email me at drmott@drmott.com if you would like help securing services from other community professionals who can meet your family's needs.