Patient Forms

Hello there!

 

Please set aside about 30-45 minutes to read and complete the required paperwork below.  I apologize for the amount of paperwork, but I promise you it will enhance your treatment experience! Bring all completed paperwork with you to session.  ***Due to COVID-19 making therapy a virtual process for the moment -  paperwork will need to be mailed in, dropped off during business hours, faxed, or sent via attachments - please ask me for details.

 

I look forward to meeting you soon!

 

 

Here is the link to TA so you can log in to fill out the contact and insurance information and see it's other convenient features/benefits:

 

https://www.psychselect.com/cgi-bin/TherapyAppointment/login.cfm?practitioner=6071&CFID=79181&CFTOKEN=a159efbb3b59faea-3BDAEDBF-DE27-56A0-E26F4B4A70E7D14E

Client Intake
Each participant is asked to complete this form to the best of their ability. Parents may need to assist their children as they may not know all of the information.
Client Intake 2018 PDF.pdf
Adobe Acrobat document [202.3 KB]
Yearly Update Form/Returning Client Form
If you are returning client, or if you are a client who has been with me for over 6 months and it is a new year, you will need to download, print out, and complete this form.
Yearly Update and Assessment Form.pdf
Adobe Acrobat document [125.6 KB]
Signature packet 08.2020
This is a required document for all participants that includes the Informed Consent for Treatment and the Notice of Privacy Practices (HIPAA NPP). Multiple participants may sign at once. Parents sign for minors and minors also sign in addition to parents. It is important that parents help their minor children to understand what they are signing. If there are any questions about this document after reading it - please contact EH prior to signing for understanding.
Signature Packet (08:2020).pdf
Adobe Acrobat document [192.2 KB]
Insurance Information Form
Anyone that plans to use their insurance benefits for therapy will need to complete this form. It requires a call to the insurance company to verify benefits or that the client go onto their insurance company portal to verify their benefits.
Insurance Information Form 12.22.18.pdf
Adobe Acrobat document [89.9 KB]
Employee Assistance Program (EAP) Information Form
Anyone who intends to use their Employee Assistance Program benefits for therapy will need to complete this form. It requires a call to the EAP company to attain authorization and benefit details.
EAP Information Form version 12.22.18.pd[...]
Adobe Acrobat document [79.0 KB]
Walk and Talk Therapy Informed Consent Addendum
Private Pay clients wishing to participate in Walk and Talk Therapy with EH will need to download, print, read, understand, agree to, and sign this Addendum/Waiver.
Informed Consent Addendum:Waiver for Wal[...]
Adobe Acrobat document [73.2 KB]
No Secrets
Clients who will be participating in therapy as a group (e.g. dyads +) will need to complete this form.
No secrets 11.1.12.pdf
Adobe Acrobat document [420.7 KB]
Supporting/Adjunct/Family Member Service Agreement
This form is for any individual client who will be having a support or adjunct join them in their therapy appointment. Any example would be a client who has signed up under insurance or EAP who will be having their family member or partner join them in therapy.
Therapist-Family Member Service Agreemen[...]
Adobe Acrobat document [51.7 KB]
Non-Intact Family Agreement
Minor under the age of 18 who comes from non-intact homes/a home in which custody is shared between parents/guardians will need to have the consent of all legal guardians to attain treatment with EH. This form is required and will need to be filled out by the guardian who is not initiating therapy/attending therapy with the minor.
Non-intact family agreement.pdf
Adobe Acrobat document [72.7 KB]
Authorization to Release or Exchange Information
Clients who wish for EH to speak with anyone on their behalf will need to complete this form granting EH authorization. All persons who have EVER attended therapy with the Client will need to also sign authorizations as per F. S. 491.0147 (2).
REOI for PP version 11.1.12.pdf
Adobe Acrobat document [485.4 KB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.


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