If you're a new client, please print and review the following forms prior to your session. If you have any questions concerning the content of the Notice of Privacy Practices and the Statement of Understanding, please feel free to raise them during the initial meeting.
Additionally, please complete the following forms and bring them to your first session along with your payment or co-payment, your insurance card or your EAP Company's name, phone number and authorization number.
- Acknowledgement of Receipt of Notice of Privacy Practices
- Acknowledgement of Receipt of Statement of Understanding
- Face Sheet
- Telemedicine Informed Consent
- Credit Card Authorization Form
If you would like me to coordinate care with another agency or treatment provider (e.g., psychiatrist, primary care physician), you must first complete the following form to authorize mutual exchange of your private health information.
Other helpful forms:
- Application for Crime Victim Compensation (http://www.vcgcb.ca.gov/docs/forms/victims/apps/handprintapp_English.pdf)
Note: To download Adobe Acrobat Reader for free, click here.