INTAKE FORMS
All of the forms described below can be downloaded in a single PDF file here. If you are seeking other services besides individual psychotherapy, please contact me for the corresponding forms.
Practice Information & Consent to Treatment for Individual Psychotherapy
This form contains detailed information about my practice, including information about appointments, fees & insurance, and cancellation policy. Your signature on this form lets me know that you understand the policies of my practice and that you agree to enter into treatment with me under these conditions.
Informed Consent for Telepsychology Services
This form discusses some of the differences between in-person psychotherapy and telepsychology, as well as some of the risks and special considerations to keep in mind when engaging in remote services. Your signature on this form lets me know that you are aware of these risks and considerations and that you agree to use a secure teletherapy platform that I have selected for our remote sessions.
Notice of Privacy Practices
This form lets you know how medical information about you may be used or disclosed, and how you can get access to this information. It is similar to the notice of privacy practices that you receive from your primary care physician.
Consent to Use & Disclose Your Health Information
Your signature on this form lets me know that you have read my Notice of Privacy Practices (see form above) and that you agree to let me use your protected health information and to send it to others for the following purposes:
To decide on what treatment is best for you and to provide treatment to you
To arrange payment for your treatment
To help carry out certain business or government functions
To help provide other treatment to you
Fee Agreement
Your signature on this form means that you agree to pay for the services I provide to you.
Client Basic Information Form
This form gives me basic information about you, so that I will know how to contact you and have other information that I need for administrative purposes.