Forms

By your first appointment, please read the HIPAA form notice (no need to print this page) and print, fill out, and sign the last three documents (HIPAA acknowledgement, intake form, contract).  The release of information form is needed when a client desires that we talk or exchange paperwork with another provider or friend/family member. Thank you!

HIPAA Form

This is a statement regarding how we utilize your PHI (private health information).

HIPAA Privacy Notice Acknowledgement 2019

Please sign this to acknowledge receipt of the HIPAA form above.

Pediatric Intake Form

This is a case history form so we can have a better understanding of how to work with your child.

Private Client Contract (Updated)

This has information pertaining to fees, scheduling, and other important business information.

Release of Information

This needs to be filled out if you need to give permission for us to reach out to another provider or if another provider is requesting information from us. This is also necessary if you would like us to be able to provide health information to another friend/family member.