Please review and complete the following forms prior to your initial consultation. They can be downloaded by clicking the link below. Once completed, please bring them to your appointment or scan and email them back to me. This will save valuable time and help make the initial session much more efficient. If you have trouble accessing the forms, please let me know and I will email them to you directly. I will also review these forms and the information provided with you during your first session, as well as answer any additional questions you may have.
New Patient Forms Checklist
Treatment Consent: Provides information about various treatments including psychotherapy and medication management. Please read carefully and sign prior to your first visit.
Patient Information Adults (Ages 18+): This form collects important background information. Please fill out as much as possible. I will review this material briefly during the initial session
Patient Information Minor (Under age 18): This form collects important background information. Please fill out as much as possible. I will review this material briefly during the initial session
HIPPA Notice of Privacy Practices: Serves as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act
Receipt of Privacy Practices: Signing this form indicates that you received a copy of the HIPAA Patient Privacy Notification
Consent for Release of Information: This form is very important if there are others that need to be contacted regarding your case. Important individuals often include family members, previous clinicians, primary care doctors, etc. Please remember that confidentiality is a pillar of mental health care. Therefore, you are always in charge of who receives information and is included in the treatment process.
Credit Card Authorization: Since I will hold appointment times for you, I, in return, request that you fill out this form. Without discussing it with you directly, your credit card will only be charged in the following situation: (a) cancellation less than 48 business hours in advance of your appointment, (b) no show for appointment, (c) additional services rendered agreed upon by you (i.e, phone sessions, report writing, etc.), and (d) lack of payment for appointments.
Insurance Information: I am an “out-of-network provider”, which means that I do not contract with insurance companies and cannot submit claims on your behalf.
However, you can submit a receipt/claim form to your insurance carrier after our visits and may receive reimbursement. You will need to confirm this with your specific insurance carrier.
Payment for service is due at the end of each appointment and can be made with cash, check, credit or HSA card.