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As a new client you must bring the following forms, filled in and signed, to your first appointment. I cannot treat you without your consent and completion of these forms.
Notice of Privacy Practices Consent Form
By signing this HIPPA consent form you acknowledge that you have read the Notice of Privacy Practices and understand how my office may collect, use, and/or disclose health information about you. It is based on the 2003 HIPPA law. If you have been to a medical or dental office since 2003 you have been asked to sign a similar document regarding the privacy of your health information. You can read more about your health information privacy rights on the Department of Health & Human Services HIPPA web site.
Professional Policies and Consumer Rights and Responsibilities
This consent form outlines my office policies, rights, and responsibilities regarding our treatment contract. Please read this document carefully and download a copy to keep with your records for future reference. By signing this document (in two places) you are consenting to treatment and agree to the terms and conditions of my office policies. You are also agreeing to take financial responsibility for your account and agree to the fees and payment terms outlined in this document.
You will also bring either A. B. or C. below, depending upon the service you are seeking.
A. Client Information Sheet: Adults
Individual adults, please complete and bring to your first session this Client Information Sheet.
B. Client Information and Consent Forms: Couples
If you are seeing me as a couple for relationship/marital counseling, complete these forms together and bring them to your first appointment: Client Information-Couples/Families and Couples Treatment Consent
C. Client Information Sheet: Children/Adolescents
If I will be seeing your minor child, please fill out this Child/Adolescent Information Sheet. This document must be filled out and signed by you (the parent or legal guardian) prior to my first session with your child. This document provides me with some basic information about yourself and your child. It is designed to help start the process of getting to know you and your family, reveal why your child is coming to me for counseling, and guide me to be most helpful to you and your child.