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Forms

Please download, print, and complete all relevant forms in advance. Please see the instructions below regarding which forms are necessary and how to proceed.

 

Instructions:

1.     All patients should complete the Registration form, Disclosure Statement, and Informed Consent Form and sign the appropriate signature page (adult or child). Please note that teens, age 15 and over, must sign in addition to parent signature.

2.     Complete either Adult History or Child/Family History form.

3.     Please complete, sign, and date the Electronic Payment Authorization form.

4.     Please sign and date the last page of the HIPPA (Privacy) notice, Consent for Treatment, and initial the Policies form and letter to parents form ( the letter is for children and adolescent clients, only) .

5.     If you would like me to share or obtain information related to your treatment from other providers or individuals, please also complete and sign the Release of information.

6.     Please also read the Social Media Policy. Signing the consent form indicates you have read this policy.

7. If you are a Cigna member, please complete the Authorization to Bill Insurance form. Please note I do not take all Cigna plans.

 

Forms and Packets:

Child/Adolescent Packet Forms

Adult Packet Forms

Release Exchange of Information Form 

Authorization to Bill Insurance

Text and Email Agreement