If you are a new patient, please complete the following forms and bring them with you to the initial appointment:
Adults: the Informed Consent Agreement; the Adult Patient Information Form; and either the insurance or private-pay Financial Responsibility Agreement.
Adolescents: the Informed Consent Form, the Adolescent Patient Information Form, the relevant Financial Responsibility Agreement Form, plus the Adolescent Agreement for Psychotherapy.
If you have not already read a HiPAA Information Form provided by another doctor, please read it under the Privacy Policy link before we meet.
Right click on the PDF icons beside each description to open the forms I have described.
Patient Information Form – Adult
Basic information form for new adult patients. Please bring it to our first meeting.
Patient Information Form – Adolescent
Basic information form for new adolescent patients. Please bring it to our first meeting.
Informed Consent Agreement
Informed consent agreement and description of policies and process of therapy. Please bring to our first meeting.
Adolescent Agreement for Psychotherapy
An agreement between parents and adolescents about the rights of minors to confidentiality in treatment. Please discuss this with your adolescent (or parent) and bring a signed copy to the first session, in addition to the signed copy of the Informed Consent Agreement described above.
Financial Responsibility Agreement Using Insurance
This authorizes me to file claims with your insurance carrier.
Financial Responsibility Agreement – Private Pay
Please complete this form if you will be paying for treatment services with no insurance reimbursement.