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Forms

Please download and complete all forms and bring them to our first appointment

For clients 18 and younger or still in high school

  1. Client Information Form
  2. Child History Form (18 and younger)
  3. HIPAA Statement
  4. Disclosure for Treatment
  5. Informed-Consent-Checklist-for-Telepsychology-Services
  6. Authorization for Release/Exchange of Information
  7. Communications Policy

For clients 19 and older

  1. Client Information Form
  2. Adult Personal History Form (19 and older)
  3. HIPAA Statement
  4. Disclosure for Treatment
  5. Informed-Consent-Checklist-for-Telepsychology-Services
  6. Authorization for Release/Exchange of Information
  7. Communications Policy

Notice: No Surprise Act Medical Bills

View: Right to Receive a Good Faith Estimate of Expected Charges

View: Your Rights and Protections Against Surprise Medical Bills

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