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
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