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Lackawanna County
Blakely PA
Carbondale PA
Clarks Summit PA
Moosic PA
Downtown Scranton PA
North Scranton PA
Pike County
Matamoras PA
Northampton County
Bethlehem PA
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Berwick PA
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Wilkes-Barre, PA
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West Pittston PA
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Tunkhannock PA
Montour County
Bloomsburg PA
Danville PA
Contact
570.961.3361
Home
Our practice
Administrative Staff
Therapists
Job Opportunities
Counseling Services
Telehealth
Careers
FAQs
Media
Locations
Lackawanna County
Blakely PA
Carbondale PA
Clarks Summit PA
Moosic PA
Downtown Scranton PA
North Scranton PA
Pike County
Matamoras PA
Northampton County
Bethlehem PA
Columbia County
Berwick PA
Luzerne County
Wilkes-Barre, PA
Kingston PA
West Pittston PA
Wyoming County
Tunkhannock PA
Montour County
Bloomsburg PA
Danville PA
Contact
✕
Home
Our practice
Administrative Staff
Therapists
Job Opportunities
Counseling Services
Telehealth
Careers
FAQs
Media
Locations
Lackawanna County
Blakely PA
Carbondale PA
Clarks Summit PA
Moosic PA
Downtown Scranton PA
North Scranton PA
Pike County
Matamoras PA
Northampton County
Bethlehem PA
Columbia County
Berwick PA
Luzerne County
Wilkes-Barre, PA
Kingston PA
West Pittston PA
Wyoming County
Tunkhannock PA
Montour County
Bloomsburg PA
Danville PA
Contact
Insurance
Insurance
Client Name
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Date
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Date of Birth
*
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EAP Auth Number
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Insurance Card
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Name of Insured
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Consent
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I agree to the payment policy.
Although this office will process claims by billing insurance companies, I understand that payment for insurance deductibles and co-pays are my responsibility. We do not impose any charge for no-show/late cancellation appointments, nor do we use collection agencies for outstanding late payments. By signing below, I give permission for submission to my insurance company.
Consent
*
I agree with the billing policy
In signing this document, I acknowledge and consent to John G. Kuna, Psy.D., Pennsylvania State Licensed Psychologist (License # PS016759), in supervising our therapy sessions.
I understand that Dr. Kuna will sign the claims submitted to the insurance company as the Supervising Psychologist. As such, I accept full responsibility for the charges incurred by my therapy sessions.
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