Forms

Important Therapy Documentation

If you are considering therapy provided by Therapy For Kids for yourself or a family member, please review the following documents and download the required forms. Please read all of the documents carefully. Fill out the 4 forms marked with * and bring the completed forms to your first appointment. Preparing these forms for the first session will allow us to proceed quickly and use the session to best advantage.

Consent for Care*

This document provides information about clinical services that I provide and represents an Agreement of consent for care.

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Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information

This notice describes how psychological and medical information about you may be used and disclosed and how you obtain access to the information. Please review it carefully.

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Release of Information*

This document provides you with control over what protected health information is disclosed, who it may be disclosed to and the time this disclosure is effective. It is also the document to use to revoke any or all disclosures.

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Health Insurance Information (Intake Form)*

This document provides the information necessary for Therapy For Kids to submit charges to your health insurer or other agency to request payment for services rendered.

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Custody/Access Dispute Contract*

This contract is to obtain your written agreement that I will not be asked to participate in any litigation regarding a custody/access dispute.

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Financial Agreement

This document provides a summary of professional fees and billing practices.

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​Important Therapy Documentation

Consent for Care*

This document provides information about clinical services that I provide and represents an Agreement of consent for care.

Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information

This notice describes how psychological and medical information about you may be used and disclosed and how you obtain access to the information. Please review it carefully.

Release of Information*

This document provides you with control over what protected health information is disclosed, who it may be disclosed to and the time this disclosure is effective. It is also the document to use to revoke any or all disclosures.

Health Insurance Information (Intake Form)*

This document provides the information necessary for Therapy For Kids to submit charges to your health insurer or other agency to request payment for services rendered.

Custody/Access Dispute Contract*

This contract is to obtain your written agreement that I will not be asked to participate in any litigation regarding a custody/access dispute.

Financial Agreement

This document provides a summary of professional fees and billing practices.

Important Therapy Documentation