Forms

Each of the form links below will open a PDF file in a separate window, which you can print, fill out, and bring with you to our offices. Please make sure you complete all forms in your category (Adult or Youth).


About the Forms

Informed Consent:  Informed consent stems from the mental health provider’s ethical duty to ensure that the client or their legal guardian is involved in decisions about his or her own treatment. The process of ensuring informed consent involves information exchanged between psychologist and client and is a part of client education. In words the client can understand, the psychologist conveys the details of a treatment or procedure, its potential benefits and serious risks, and any feasible alternatives. The attached document covers this requirement. Please print it, review it, and if no questions sign it. At the first appointment we review informed consent and any questions are answered.

Intake Forms:  This form provides a variety of information needed at the first appointment.  Demographic information includes your legal name, address, phone numbers, and an emergency contact.  We also request information about medication, substance use, past providers, and interests to help us better understand you.  Finally, there is a symptoms checklist that helps the psychologist to understand your reasons for seeking assistance.  Please print this, complete it, and bring it to your initial appointment.  If the individual referred is 18 and still in high school, please complete the youth intake form.

Privacy Practices:  This notice describes how medical information about a client may be used and disclosed and how a client or their legal guardian can obtain access to this information.

Child Therapy Terms & Conditions:  In order for a child, especially an adolescent, to feel safe enough to benefit from psychotherapy, they need to know that what they share is protected.  Often families end up in legal proceedings such as divorce and youth are reluctant to share their concerns because of fear that the psychologist could end up in court sharing what was said or their parents could request such information to use against the other parent or against the youth.  This form ensures that both parents agree that they will not review the youth’s medical record and will not subpoena the psychologist or the record should a matter involving their child end up in court.  Please print it, review it, and if no questions sign it.  We also review this document at the first appointment and answer any questions you might have.

Coordination of Care:  To help ensure that a client’s medical and mental health needs are addressed and services coordinated, we ask our clients to allow us to coordinate care with your primary care provider.


Good Faith Estimate

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law (No Surprises Act), health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service. You can also ask your health care provider for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the Federal No Surprises Help Desk at 1-800-985-3059.