PLEASE CLICK ON THE ICON FOR EACH OF FORMS 1, 2, 3, and 4.
FILL OUT ALL 4 FORMS.
If you will have a face to face initial session, please PRINT THEM OUT, AND BRING THEM TO YOUR FIRST APPOINTMENT (if necessary, you may let me know in advance to have the forms waiting for you to fill out before your first appointment, and you may arrive at least 15 minutes early to complete them).
IF YOUR FIRST APPOINTMENT WILL BE BY VIDEO, you will be able to send them securely from your computer through the telehealth platform.
I look forward to getting to know you.
1. PERSONAL INFORMATION
2. PRACTICE POLICIES AND FEE AGREEMENT
3. INFORMED CONSENT TO PSYCHOTHERAPY
Form # 5 is only if you are covered by Medicare:
I am "Opted Out", which means that you cannot submit claims to Medicare for reimbursement for my services.
Medicare requires that you sign the following form agreeing to that.
5. PRIVATE MEDICARE CONTRACT
Form #6 is only if you wish or need to give consent for me to communicate with other providers
(for example, a psychiatrist, another psychologist, your physician)
6. RELEASE OF INFORMATION FORM
Form #7 is only if you require my participation in a legal proceeding
7. FEES AND POLICIES FOR LEGAL PROCEEDINGS