Forms

Billing-Insurance Information Form gives you information about my policies and procedures; fees for intake and ongoing psychotherapy sessions; private pay fee agreement; assignment of benefits for insurance; asks about client and insurance information. (2 pages) Read, complete and sign all relevant sections of both pages.

Credit Card Payment Authorization Form provides the option for you to charge your session fees, copays, deductibles and balances directly to your credit card. (1 page) Read, complete and sign.

Intake Questionnaire asks for information about you, the issues that bring you in to see me and your treatment goals so that I can best provide services for you. (2 pages) Complete entire form.

Informed Consent explains informed consent as my client. (1 page) Read and sign.

Health Insurance Portability and Accountability Act (HIPAA) Privacy Practices Form describes legal use and disclosure of health information. (4 pages) Read.

Receipt of HIPAA Privacy Practices Form acknowledges that you have received and understand the HIPAA form. (1 page) Read and sign.

Client Bill of Rights and Grievance Procedure tells you your rights as my client. (1 page) Read.

Insurance Benefits Worksheet provides information and questions to ask your insurance company to get accurate information about your mental health benefits. (2 pages) Complete and use as reference when calling insurance company to clarify benefits.

Authorization For Release of Information authorizes release of information to and from another person, for example psychiatrist or former therapist, for your benefit, i.e. in order to coordinate services for you. (1 page) Read and complete name, contact information and dates of contact for person with whom I will share information. I will complete the rest of the form with you in my office.

MCPST E-Communication Form offers clients the ability to communicate with therapists via electronic mail, patient portal, telemedicine and text notification.