New Patient Forms for Psychiatric Services
Please complete the following forms prior to your initial consultation. They can be printed by
clicking on each link below. Once completed, please remember to bring them with you to your
appointment. This will save valuable time and help make the initial session much more efficient.
If you have any trouble accessing the forms, please alert us immediately and we will send
you copies via email or USPS. We will also review these forms and the information
provided with you during your first visit, as well as answer any additional questions.
New Patient Forms Checklist
Treatment Consent: Provides information about various treatments including psychotherapy and medication management. Please read carefully and sign prior to your first visit.
Patient Information: This form collects important background information. Please fill out as much as possible. We will review this material briefly during the initial session.
HIPAA Notice of Privacy Practices: Serves as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act.
Receipt of Privacy Practices: Signing this form indicates that you received a copy of the HIPAA Patient Privacy Notification.
Consent for Release of Information: This form is very important if there are others that need to be contacted regarding your case. Important individuals often include family members, previous clinicians, primary care doctors, etc. Please remember that confidentiality is a pillar of mental health care. Therefore, you are always in charge of who receives information and is included in the treatment process.
Insurance Information: We do not participate in any insurance panels and will not bill your insurance directly. However, we can provide you with a receipt for services rendered. This can often be submitted to your insurance company who may offer reimbursement to you directly for out-of-network services. Although we are not involved in this reimbursement process, it is still important for us to facilitate potentially getting medications and other services covered.
Credit Card Authorization: Since we will hold appointment times for you, we in return request that you fill out this form. Without discussing it with you directly, your credit card will only be charged in the following situation: (a) cancellation less than 48 business hours in advance of your appointment, (b) no show for appointment, (c) additional services rendered agreed upon by you (i.e, phone sessions, report writing, etc.), and (d) lack of payment for appointments.
New Patient Forms Checklist
Treatment Consent: Provides information about various treatments including psychotherapy and medication management. Please read carefully and sign prior to your first visit.
Patient Information: This form collects important background information. Please fill out as much as possible. We will review this material briefly during the initial session.
HIPAA Notice of Privacy Practices: Serves as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act.
Receipt of Privacy Practices: Signing this form indicates that you received a copy of the HIPAA Patient Privacy Notification.
Consent for Release of Information: This form is very important if there are others that need to be contacted regarding your case. Important individuals often include family members, previous clinicians, primary care doctors, etc. Please remember that confidentiality is a pillar of mental health care. Therefore, you are always in charge of who receives information and is included in the treatment process.
Insurance Information: We do not participate in any insurance panels and will not bill your insurance directly. However, we can provide you with a receipt for services rendered. This can often be submitted to your insurance company who may offer reimbursement to you directly for out-of-network services. Although we are not involved in this reimbursement process, it is still important for us to facilitate potentially getting medications and other services covered.
Credit Card Authorization: Since we will hold appointment times for you, we in return request that you fill out this form. Without discussing it with you directly, your credit card will only be charged in the following situation: (a) cancellation less than 48 business hours in advance of your appointment, (b) no show for appointment, (c) additional services rendered agreed upon by you (i.e, phone sessions, report writing, etc.), and (d) lack of payment for appointments.