John T. Doheny III, Licensed Professional Counselor, Master Addiction Counselor


Phone-706-575-1833           Fax-706-324-2088

If you plan to use insurance (requires a mental health or substance use disorder diagnosis) please bring your identification and insurance card to your first appointment. If you are not the primary insurance holder you will need to be able to provide that person's complete name, birth date and Social Security number.

Please be prepared to pay your co-pay or deductible. If you are unsure of the amount then you will need to pay a minimum of $20.00

The fee for the initial visit is $130.00. If you are planning to private pay please be prepared to pay that fee with cash (preferred), check, or credit card. Those using an Employee Assistance Program will not have a co-pay or deductible but an authorization number must be obtained prior to the first session. Thank you.

FORMS

Please click to open the necessary forms, print and complete.  Please do not leave blank spaces.  If a particular line does not apply please indicate by writing "N/A".  Thank You.

Personal Information-(Click to open) Please print this form, fill it out and bring it with you to your first session.

Informed Consent-(Click to open)  This is a copy of the Informed Consent that is included in the Personal Information Packet.  Please make a copy for your personal files. 

Authorization for Release of Information-(Click to open) Please complete this form if you need information about your therapy sent to anyone, i.e. personal physician or psychiatrist, attorney, probation officer, employer, etc. This form is also for young adults, over 18 years of age, who would like their parents to be informed of attendance or other information. Note that you have the right to revoke this authorization at any time.