Forms

FOR NEW CLIENTS — You will need to complete and sign a couple of things before we start therapy.  It’s easiest if you print and bring these with you to your first appointment, but if you don’t have access to a printer, we will do it together when we meet.  If you have questions about any of these forms or information, we can discuss those at our first session.

Confidentiality and Privacy Practices  You don’t need to print this.  It is here for you to review so you understand how I keep our work together confidential and protect your privacy.

Disclosure Statement  Please print this, read, and sign the last page.  This explains important information about my background, how I practice, your rights, and my practice policies.

Billing Authorization  Please print this form, complete, and sign.  If you are using your insurance benefits to help pay for the services I provide, this authorizes me to bill your insurance company.  Also, I ask for a credit card number to be kept on file which can be used for co-pays or other fees.

Release of Information  You only need to fill this out if there is someone you would like me to consult with about our work together, or someone who you will want me to speak with about any matter, such as billing or appointment scheduling.  This might be your physician, parent, spouse or anyone else.  Remember that our work together is confidential, and in most cases I will need your written consent to talk with anyone else.