Informed Consent

Welcome to NYC Affirmative Psychotherapy LCSW PLLC (NYCAP). Here follows some
essential information about our psychotherapy services. Please read and sign at the bottom
to indicate that you have reviewed this information. The policies and/or procedures may
change at any time and you would be subject to those changes. We will inform you when
changes do arise.
Length and Frequency of Treatment
Psychotherapy here involves regular weekly sessions, usually forty-five to sixty minutes in
length. We provide psychotherapy via a HIPAA compliant video platform or phone. Please
note that by booking an appointment with me you are agreeing to the specific day and time
each week. Also, I don't work with folks at a different frequency example: bi-weekly or once
per month. We only work with folks on a weekly basis.
Confidentiality
All staff psychotherapists are licensed to offer psychotherapy services and are bound by
New York State law regarding confidentiality. All LMSW (Licensed Master of SocialWorker)
staff are under clinical supervision of an LCSW (Licensed Clinical SocialWorker). Social work
interns are also under supervision of a licensed psychotherapist at the practice and are
bound by the same laws. Information you share with your psychotherapist will be kept
strictly confidential and will not be disclosed without your written consent. By law, however,
confidentiality is not guaranteed in life-threatening situations involving yourself or others, or
in situations in which children are put at risk (such as by sexual or physical abuse or neglect).
If your psychotherapist needs to discuss your treatment with a colleague, they will take
pains to disguise identifying information, including using a synonym. Please note that email
may not be a secure form of communication.
Fees
We offer a sliding scale fee structure, you may choose to pay $70/, $90/, $125 or $175 per
session (subject to availability). We do not ask for proof of income when deciding the fee.
We ask that you pay at the rate you can afford and feels right to you, doing so allows us to
provide psychotherapy to a diverse array of folks and continue to provide sustainable
psychotherapy to the community at large. Please note there will be a $5 fee increase to your
sliding scale rate after each full year your are in therapy here. This helps the practice
maintain sustainability while keeping initial rates low. It is also expected that as your income
improves that you will move up to the appropriate sliding scale fee to open up the lower
rate for other members in community seeking mental health treatment.
All other Paperwork/Form Completions, and Other Letters of documentation requested are
$35 per form or letter.
Cancellations, Missed Sessions and Rescheduling
Please note we are a remote only practice and only work with folks on a weekly basis. We
ask for 48 hours notice for any cancelling or rescheduling for a different week so we can
attempt to fill the appointment time. All appointments that are rescheduled for a different
week, cancelled with less than 48 hours notice or missed will be charged the regular fee for
that appointment via card on file for you. For WellFleet, Empire, AETNA, OPTUM, and any
other insurance carriers we charge a flat rate of $80. If you need to miss more than 2
sessions in a row for any reason you will need to pay the cost of the session for each

Luna Becerra-Lewis License LMSW #121004 19 W. 34th St. Penthouse New York, NY 10001-3006 (347) 625-5020 Page 1 of 2
following session missed to hold that time slot.
Please note that the work of therapy requires a commitment to your healing and because of
that we limit the number of cancelations within one year to five. After five canceled sessions
you will be charged for each missed/canceled session thereafter.
Insurance
We are in-network with WellFleet Student Health, Aetna, and Empire BCBS commercial
insurance plans. Please note you are financially responsible for any sessions the insurance
company will not cover. You will be provided an estimate of your out of pocket costs before
your first session. Final determination of patient responsibility is made by your insurance
company at the time of claim processing.
Payment
Payment is due at time of treatment. You will need a credit or debit card to keep on file for
future appointments. Payment is only accepted via credit or debit card and includes a small
processing fee for all fee levels including those using insurance topay for co-pays or
coinsurance. The sliding scale rates which include fees for using a credit or debit card are as
follows: $70/ $90/ $125/$175.
Physician Contact
Physical and psychological symptoms often interact. Your psychotherapist will encourage
you to seek medical consultation if warranted. In addition, medication may sometimes be
helpful for psychological problems. When appropriate your psychotherapist can assist you
in obtaining a referral for a medication evaluation.
Freedom to Withdraw
You have the right to end psychotherapy at any time. Your psychotherapist will encourage
that you have sufficient time to talk about ending and next steps.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD
AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Client

Lilian Ma
Signed by Lilian Ma
October 4, 2023 at 6:26 pm
IP address: 172.58.227.109

Luna Becerra-Lewis License LMSW #121004 19 W. 34th St. Penthouse New York, NY 10001-3006 (347) 625-5020 Page 2 of 2