Nancy L Scott LMFT PC
1234 Pearl St., Suite 3
Eugene, Oregon 97401
Nancy schedules appointments Tuesday-Friday. She returns calls Monday-Thursday. Voicemail messages are welcome at any time, however her office is not staffed to provide emergency or on-call services.
If you have spoken with Nancy by phone and set up your first appointment, you may download & print these forms, fill them out, and bring them with you to the office. Otherwise, Nancy will provide them at the close of your first session, to be submitted after meeting in person. (These files require Adobe Reader: Visit Adobe’s website where the reader can be downloaded free by clicking on this link. )
Disclosure Statement LMFT: Licensed therapists are required to provide this general information about their practice and procedures, and to ask for your signature on it.
Client Information: This form provides background information about you for Nancy. In the family history section, please feel free to fill out as much or as little as is comfortable for you. If you begin to feel overwhelmed by writing about your family history, please feel free to stop writing and to do something that is comforting for you instead.
INSURANCE verification: This form provides billing information for Nancy’s bookkeeper, Teresa Ewoniuk. Nancy is not a participating provider on any insurance panels. However, many insurance plans pay benefits for out-of-network providers. If you wish to bill insurance, you may contact Teresa in advance to verify your benefits. Teresa may be contacted with insurance and billing questions anytime by email, tmemedicalbilling@gmail.
To determine your insurance coverage for Nancy’s services, you may also contact your insurance company directly and ask them to what extent your policy covers “out of plan providers” who are Licensed Marriage & Family Therapists.