For our first appointment, I’ll need you to fill out the following forms. Bringing them in before the meeting will cut down on time spent on paperwork!
The three forms below are needed for all clients. They cover your identification information, privacy expectations and ethical disclosures.
Contact and billing information so that I can provide statements that you can present to an insurance company if you are interested in receiving reimbursement for services.
Notice of Privacy Practices
Reading this will allow you to better understand how I maintain your privacy and protect your personal health information. Please read the paperwork fully before signing the form at the bottom which acknowledges that you have received it.
It is important for me that you know about how I work, what it will cost you, what my policies and procedures are, and all the risks and benefits of therapy before starting! Please read fully and sign at the bottom to acknowledge you have received the form.
Depending on your or your children’s situation, there may be some optional paperwork that you’ll have to fill out. Below are two examples of forms that I deal with daily.
Consent to Treat a Minor
For patients that are under 18, I need consent from a parent, guardian or conservator. If you are a single parent, I may require signatures from both you and your child’s biological father prior to starting treatment. If you have any questions or concerns about getting a secondary signature, please contact me directly.
Authorization to Release Information
I may want to speak to another health professional or important individual who may have information that can help me provide better therapeutic services. Signing this form will give me consent to contact and talk with those individuals.