Forms

On this page you will find forms that you will need to complete in order to start treatment.

The Notice of Privacy Practices is for you to keep. Please print and return the Receipt of Notice of Privacy Policy, which states only that I have provided this document to you. It does not state that you agree with it. If you have questions or concerns about it, please bring them to your session.

The Release or Authorization authorizes me to speak with someone that you designate. Except under special circumstances stated in my Notice of Privacy Practices, I will not speak with anyone about your treatment without an Authorization For Use or Disclosure of Information.

My Fee Policy constitutes our agreement for handling missed sessions. All matters associated with your treatment are open for discussion. If you have questions or concerns about my Fee Policy, please bring them to your session.

I only bill insurance directly for Medicare. If you are a Medicare patient, please sign the Signature on File form so that I can bill Medicare on your behalf without getting your signature for each session.

If you would like to use email or text messaging to communicate with me about scheduling or other non-clinical matters, please sign the Text Email Opt In form.