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Forms

  • There are 6 [7 if you are eligible for Medicare] forms to be read/completed. The forms are numbered at the top to help you keep track of which ones you have done.  My sincere apologies for the volume of paperwork. Best practice as well as current state and federal laws/regulations/codes require this documentation be provided to and signed by you.

  • Please allow yourself at least 45 minutes to read and fill out the paperwork whether you do this at home or at the office prior to your session. 
  • THE START OF YOUR SESSION WILL BE DELAYED AND YOUR SESSION WILL BE SHORTER THAN YOUR SCHEDULED TIME IF I HAVE NOT RECEIVED ALL THE PAGES OF ALL THE FORMS COMPLETED. You may drop the forms off ahead of time, email them, or bring them 10 minutes early to the first session. If you have any questions, we will address them at the time of your appointment. 
  • I have a secure [encrypted] email service you may use. Contact me to receive the log-in information. If you email the paperwork, I need it 24 hours prior to the appointment time.
  • If you need the forms printed for you, let me know when you schedule your appointment and the forms will be ready for you to complete at the office 45 minutes prior to your scheduled appointment time.
  •                                                No Surprises Act/Good Faith Estimate Notification:
  • In January 2022, Federal legislation under Section 2799B-6 of the Public Health Service Act went into effect called The No Surprises Act [NSA] to help patients seek and receive medical treatment and not be surprised by huge, unexpected charges after the fact. 
  • The piece of this act that impacts you the most is that the NSA requires providers to give a diagnosis and Good Faith Estimate [GFE] of the cost of treatment before the patient is seen. It also requires that you receive this estimate within 72 hours of scheduling your appointment. It is designed to inform you that you can seek services with someone who is contracted with your insurance company, and you are not required to work with me. You will find more detailed information in the form below.
  • If you have questions or concerns about the GFE or the NSA, Contact: 1-800-985-3059 or www.cms.gov/nosurprises. 
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  •                                                                                            MINORS 
  • I request signatures from both parents authorizing treatment and both parents present at the initial session [child NOT present]. If the child is not living with both biological parents, I will need a copy of the MOST RECENT court custody documents and request an individual session with each parent prior to beginning work with the child if at all possible. You are responsible for providing a complete copy of any updated court documents regarding your child to me at the next session. Failure to do so may mean that your child will be referred out of this practice. 
  • Children under the age of 18 can, by law, consent for their own treatment under specific circumstances. Please contact the office for more information. If your child is within 30 days of becoming 18, please have them read all the forms and co-sign with you and fill out the Adult checklist.

[Choose Adult OR Child based on the age of the client]

 

 

 

 

 

Some people have trouble completing the Release of Information. For your convenience, here is a sample. You do not need to print this out.

  • **Release of Information is needed for me to be able to communicate with members of your treatment team [doctor, dietitian or psychiatrist etc.] It is also used to communicate with former therapists, family members, treatment facilities, schools and in the case of marital or pre-marital work, each member of the couple MUST complete a release listing their partner as someone with whom I can share information. If there is no one you wish to share information with, you do not need to complete this form prior to session.
  • A release is also required if someone else is paying for treatment so that billing questions or problems may be discussed with the payor.
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