Helpful Client Forms
If you are a first time patient, please download, review, and complete the following forms found below. I will send you an encrypted email so you can email the completed forms to me through an encrypted email platform. Please remember, I will also need a copy of your government issued photo identification card or passport, and also credit card to be kept encrypted on file with Square or with IVY Pay. Thank you.
- Clinical Intake
- Consent for Psychological Services
- Credit Card Authorization Form
- Cancellation Policy Form
- SQUARE reader Electronic Authorization Form
- Notice of Privacy Practices HIPAA
- HIPAA Acknowledgment of Receipt
- IVY PAY encrypted Card Processing
- Symptoms Checklists
- ACE Questions
If you would like me to coordinate care with other providers (for example, endocrinologist, psychiatrist, et cetera) then please also complete the form.