Imani Mental Health and Wellness

Client Forms and Policies

Imani Mental Health and Wellness Clinic LLC Terms and Policies

Imani Mental Health and Wellness offers comprehensive psychiatric evaluations and medication management with adjunctive Interpersonal and social rhythm psychotherapy, health and wellness lifestyle coaching to clients aged 25-99.

Please read and familiarize yourself with the clinic’s terms, policies and procedures regarding medication management services. For a personal centered approach to be optimal, it is essential that the provider and client collaborate to enhance goals and expectations of mental health care being provided. Imani Mental Health and Wellness will let you know if your psychiatric needs require a higher level of care than we can provide and will refer you to care that matches your current situation.


Imani Mental Health and Wellness LLC takes safeguarding and protecting the client’s information seriously. Imani Mental Health and Wellness is bound by law to protect client confidentiality. Any disclosure of your treatment to others will require your explicit written consent. However, Imani Mental Health and Wellness LLC providers are mandated reporters.

If indications of child abuse, elder abuse, or planned bodily harm to oneself or to others come to light during treatment, the provider is legally bound to report these to the appropriate authorities. Clients are required to sign a statement of understanding of their rights to privacy, which will be provided via Patient Portal.

Payment at Time of Service Policy

Payment for services is due at the time of scheduling/when service is provided. Appointments canceled with at least 48 business-hours’ notice will receive a full refund of the prepayment. The prepayment will not be refunded for canceled appointments with less than 48 business hours’ notice or missed/no-show appointments. Clients must pay with a credit card.

We require that a credit card be on file prior to scheduling your first appointment.

You will be provided with information about your insurance benefits for services requested prior to scheduling, as well as information about private pay rates. Imani Mental Health and Wellness will do their best to obtain accurate insurance information prior to the appointment but it is your responsibility and recommended you check in with your insurance with regards to deductibles, copays and coinsurance

If payments are 90 days past due, Imani Mental Health and Wellness reserves the right to utilize legal resources such as collection agencies or small claims court to obtain payment for our services. A credit card will be kept on file as per the credit card authorization form and will be charged if payment is not received at the time of service.

Cancellation and No-Show Policy

We require clients to provide two business day notice of  cancellation of their appointment. If your appointment is on a Monday, it must be cancelled by the Friday.

Clients that are 15 minutes or more late for a 30-minute appointment or 15 minutes or more late for a 60-minute appointment will be considered a “no show” as providers do not have adequate time for treatment and completion of service.

Client’s card on file will be charged $150 for missed appointments or late cancellations – this may exceed the insurance company rate. Please note, insurance companies will not pay for missed sessions; payment for these sessions are the responsibility of the patient and must be taken care of before a client can be rescheduled.

If you miss an appointment and don’t contact Imani Mental Health and Wellness within 30 days, you may be subject to termination as a patient. In such cases, treatment must be re-established for further services to continue which includes medication refills.  For patients that are stable, follow up is required at least once every 3 months in order to obtain their refills and continuation of treatment plan and patient provider relationship.

Right to Terminate

Imani mental health and wellness reserves the right to terminate the provider-patient relationship under the following circumstances:

  • When payment is not received and services are no longer beneficial to the client.
  • When a client misses two consecutive appointments without notice or frequently misses appointments.
  • When a client/family member becomes aggressive, verbally abusive or hostile towards the provider and in the clinic.
  • When a client declines to honor the treatment agreement plan, does not follow the clinic’s policy on controlled substances.

Prescription Refill Policy

The practice at Imani Mental Health and Wellness is to send prescriptions electronically to your preferred pharmacy, medications provided will be enough to cover you until your next appointment. If an exception occurs, please call me to request a refill at least 5 working days before you will run out of medication. Refills will be considered on a case-by-case basis and Susan will provide one time exception for early refills. Refills will be approved only for patients with a scheduled follow up appointment. It is your responsibility to contact your pharmacy when you need a refill at least 1 week before you run out. Please note, we do not process refill requests after hours, on weekends or on holidays. One time medication dose change be made outside of scheduled appointments.

Please OPT OUT of automatic refill requests if offered this service by your pharmacy. We will not respond to pharmacy-initiated refill requests due to the significant administrative burden this entails.

Please remember that it is your responsibility to schedule a follow-up appointment before you run out of medication and within the return time frame determined in your treatment plan. Controlled substances cannot be refilled by phone and will only be written during office visits if appropriate. There will be no early refills for controlled substances regardless for the reason for the request.

It is important that we maintain contact with our clients to assure best practice, safety, and meet treatment goals. Imani Mental Health and Wellness requires that individuals receiving medication services to have routine in-office checks monthly with their provider until stable and then  at least every three months.


Imani Mental Health and Wellness does not complete disability forms and evaluations, but we can provide a copy of the health record with your consent for established clients who are working with disability lawyers.

Emotional Support Animals

We provide documentation to established clients who have been working with us consistently adhering to treatment plan, have attended all scheduled appointments and have been seen for at least 3 months

Medical records and Paperwork:

We bill an hourly rate of $85/hour for all documentation services provided to our clients outside of treatment sessions. Due to the time involved and insurance not covering documentation, there will be a charge of $ 30 for record copies and extended or complex phone calls. Letters, reports, disability paperwork, medication authorizations, or extended calls made to third parties on your behalf will also be subject to a charge based on an hourly rate

Appointment Form

Please describe in detail the issues/concerns that you wish to be seen for.
What medications and/or supplements (if any) are you currently taking?
What insurance do you currently have?

Payment will only be collected on the day of visit