FORMS

NEW PATIENT FORMS

Click on the name of the form to download a copy.  You may print these forms at home and bring them to your first appointment, or come early to the appointment to complete forms in the office.

Patient Information

Agreement for Psychological Services

Consent to Treat

Financial Policy Statement

Insurance Verification Form

Acknowledgement of Receipt of Forms  (This form acknowledges that you have received the Notice of Privacy Practices for Protected Health Information (see below).

Release of Information  If you want me to speak with another professional (e.g., teacher, mental health professional, physician) about you or your child, please sign this form. Please fill in as much contact information as you can about the other professional, including phone number and e-mail address, if you have it.

PRIVACY INFORMATION

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

 

 

 

 

Background Information Forms –  These will be given to you at the first appointment, as needed.

Child/Adolescent Client (under age 18)
Adult Client (ages 18 and older)