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Forms

 

There are a few forms to be completed before we begin working together.  These are necessary for information gathering and documenting how you would like me to handle your Personal Health Information (PHI).

 

These include Intake Forms for Adults and Couples and Adolescents (ages 17 +), a Confidentiality Agreement for Couples Statement, an Insurance Information Form, and an Authorization for Disclosure of Information Form used only for information you want released.   A HIPPA document letting you know how your privacy will be protected also is included and will need to be signed.

 

 

Intake Information - Individuals and Couples

Confidentiality Agreement for Couples

Patient Insurance Verification

Authorization for Disclosure of Information

HIPPA Notice of Privacy Practices For Patients