PLEASE CLICK ON THE ICON FOR EACH OF FORMS 1, 2, and 3.
SAVE EACH FORM TO YOUR COMPUTER .
FILL OUT ALL 3 FORMS,
PRINT THEM OUT, AND
BRING THEM TO YOUR FIRST APPOINTMENT (if you prefer, 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)
I look forward to getting to know you.
1. PERSONAL INFORMATION
2. PRACTICE POLICIES AND FEE AGREEMENT
3. INFORMED CONSENT TO PSYCHOTHERAPY
Form # 4 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.
4. PRIVATE MEDICARE CONTRACT
Form #5 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)
5. RELEASE OF INFORMATION FORM
Form #6 is only if you require my participation in a legal proceeding
6. FEES AND POLICIES FOR LEGAL PROCEEDINGS