David Haynes-Weller, Psy.D.
The Well - Red Lion Psychology
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FORMS

Below you will find links for various documents that you need to read before your first appointment (Notice of Privacy Practices,  Consent to Use and Disclose Health Information, Insurance Authorization and Disclosure, and Financial Policy).  When we meet, I will review this information and you can ask any questions you may have about the forms. I will then have you sign the Consent to Use and Disclose Health Information form at your appointment.


Notice of Privacy Practices, Long Form:
/uploads/2/2/3/6/22367834/notce_of_privacy_practices_long_form.pdf

Notice of Privace Practices, Short Form:
/uploads/2/2/3/6/22367834/notice_of_privacy_practices_short_form.pdf

Consent to Use and Disclose Health Information Form:
/uploads/2/2/3/6/22367834/consent_to_use_and_disclose_health_information.pdf

Insurance Authorization and Disclosure Form:
/uploads/2/2/3/6/22367834/insurance_authorization_and_disclosure.pdf

Financial Policy:
/uploads/2/2/3/6/22367834/financial_policy.pdf


If you would like me to coordinate your care with a physician, psychiatrist, guidance counselor, teacher, pastor, or another professional, we will complete the Authorization Form together at our first appointment. 


After reading the above documents, please download the following form, save it, complete it, and you can email this back to me before your appointment. Please note that email is not secure so you may prefer the printable forms instead (see below).


Patient Information Form:
/uploads/2/2/3/6/22367834/patient_info_form.pdf



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