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Helpful Forms

Before We Meet:

CLIENT SERVICES AGREEMENT: My Client Services Agreement form explains my office procedures and agreement for psychotherapy services. This includes important information about your confidentiality. If you have questions after reading this form, please bring them up when we meet.

HIPAA: I am required by law to provide you with a copy of the HIPAA Notice of Privacy Practices so you can understand your rights and protections related to the use and disclosure of your identifiable health care information.

DISCLOSURE OF DUAL RELATIONSHIPS

Print, Complete & Bring to Your First Session:

CLIENT CONFIDENTIAL INFORMATION FORM: Prior to our first session, please complete my Client Confidential Information Form and bring it to our first appointment. This will help you share important details with me while allowing our first meeting to unfold more naturally.

FINANCIAL AGREEMENT AND CREDIT CARD AUTHORIZATION: My financial agreement and credit card authorization form explains my financial policies and agreement for psychotherapy services. This includes important information about my fee schedule, insurance reimbursement, other service fees, and credit card on file information.

ACKNOWLEDGMENT OF NOTIFICATIONS: Once you have read my Client Services Agreement, my Financial Agreement and Credit Card Authorizations, and the HIPAA Notice of Privacy Practice form, please sign my Acknowledgment Form. This states that you have access to and have read all forms. Bring this to our first session.

AUTHORIZATION TO RELEASE INFORMATION: There may be times when you and I agree it would be helpful for me to speak with another person to coordinate your care. With the exception of the situations outlined in the HIPAA form, I cannot do this without your written consent. Usually, we will speak about this in person and you will sign the form in my office. However, if you’re unable to meet with me, you may complete my Authorization to Release Information Form and send it back to me.Note: To download Adobe Acrobat Reader for free, click here.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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Helpful Forms

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