1.  Privacy/Confidentiality Agreement

 

This form provides for the privacy and confidentiality of your personal and your medical information.  This form is a legal safeguard for you.

 

INSTRUCTIONS:

 

1.  Click on the form icon.

2.  Print.

3.  Sign and date.  If you are a minor, your parents must also sign and date this form.

4.  Bring this signed form with you at our first interaction.  We must have this form

     completed before we can begin assessing or treating you.

2.  New Patient Intake

 

This form provides basic information about you, the patient.

 

INSTRUCTIONS:

 

1.  Click on the form icon.

2.  Complete ALL information in the form.

3.  Print.

4.  Sign and date.  If you are a minor, your parents must sign and date this form.

5.  Bring this signed form with you at our first interaction.  We must have this form

     completed before we can begin assessing or treating you.

3.  Authorization to Release Health Records

 

This form provides your authorization to release your health records to those healthcare professionals, insurance companies, and other organizations in which it is necessary to provide you with the best treatment possible.  You will be contacted before we release these records.

 

INSTRUCTIONS:

 

1.  Click on the form.

2.  Complete ALL information in the form.

3.  Print.

4.  Sign and date.  If you are a minor, your parents must sign and date this form.

5.  Bring this signed form with you at our first interaction.  We must have this form

     completed before we can begin assessing or treating you.