new patient forms
We make sure all our new patients feel welcome, safe and taken care of.
For a shorter time in the waiting room please fill out the New Patient Form and email it to us before your visit.
Effective March 1st, 2020
Dr. Craig Chepke, MD:
Initial Consultation: 60-75 min $450
Standard Follow-up appt: 45 - 50 minutes $350
Brief Follow-up appt: 20 - 25 minutes $250
Miscellaneous physician services, per 15 minutes: $80*
Timothy Balisky, MSN, APRN, PMHNP-BC:
Initial Consultation: 60-75 min $300
Standard Follow-up appt: 45 - 50 minutes $250
Brief Follow-up appt: 20 - 25 minutes $150
Miscellaneous clinician services, per 15 minutes: $50*
Tiffany Chepke, LCSW
Integrative Health and Wellness Coaching/ Therapy sessions:
- Creating Change: 1 free consultation, 1 introduction session, 3 intermediate sessions, 1 closing session $700 – Optional Email access: $50
- Investing In Yourself: 1 free consultation, 1 introduction session, 4 intermediate sessions, 1 closing session and complementary email access $850
- Making It Last: 1 free consultation, 1 introduction session, 7 intermediate sessions, 1 closing session and complementary email access $1000
10% discount for all packages paid in full prior to first session
- Initial Consultation 60 minutes: $200
- Individual Follow-up 45 minutes: $150
- Initial Consultation 60-90 minutes: $250
- Couples/Family Follow-up 60 minutes: $200
Other Fees and Information
Pharmacogenomic testing should be completed before initial consultation. Fees from laboratory may apply, billed separately.
Pharmacogenomic Testing for non-consulting patients $55 (fee from laboratory billed separately)
Prescription refill service outside of appointment: non-controlled substances $40* , Controlled substances $85* – Applies to any medications phoned, faxed, sent electronically, or mailed outside of an appt.
Staff-Miscellaneous admin fee, per 15 minutes: $20* – Examples include completion of paperwork or letters, clinical phone calls or emails, and appeal of prescription benefits.
*All services provided outside of standard business hours (9AM — 4PM Mon-Fri) are billed at twice the standard rate.
No personal checks or cash accepted.
Please note that the practice policies, regulations, procedures, and fees in these forms are subject to change without prior notice.