Please review the intake paperwork prior to your first appointment with me. I know it’s a lot, so thank you for taking the time to do it. All forms will be shared with you via client portal. Should you have difficulty accessing the forms, you can also download these, print/complete and bring in to your appointment.
6. Insurance Information Form – Please complete and sign if you plan to use your insurance for services.
If the primary insured is someone other than client, please also complete an authorization to share PHI for the primary insured (for billing purposes). Download
If the primary insured is someone other than client, please also complete an authorization to share PHI for the primary insured (for billing purposes). Download
7. Payment card authorization – Person responsible for payments needs to complete and sign. Download
8. Authorization to share personal Health information – Please complete for any provider involved in your care. Alternatively, please complete the form declining the sharing of PHI (see below).Download
8b. Declining to authorize sharing of PHI. – Please sign if you do not wish to have your clinician coordinate care.Download
9. Emergency Contact Form – Please complete and sign for any personal contact you want involved in your care, including but not limited to a person whose insurance you are on and persons responsible for payments of services. Should you decline to list any emergency contacts, please sign the form declining to do so (see below).Download
