Intake Forms:
Psychological Services

These forms are available for you to fill out prior to your intake session at  Psychological Services. If you have any questions or concerns, you may call the therapist you are scheduled to see. You will also have the opportunity to bring up questions or concerns in session. However, it can save time to have the forms filled out before the intake.

Intake Form

Please complete as many of the questions on the intake form as possible.

Intake Form

Office Policies and Procedures

Please read through the form. Please note that item #3 discusses your therapy fee; this will be discussed further at the intake session. Please sign on the line that says “Patient” and date it. You may leave the “Witness” line blank.

Policies and Procedures

Consent for Audio/Video Recording

For training purposes and to maximize quality of care, audio and video recordings of therapeutic interactions is mandatory. Please note that these videos will only be reviewed by your therapist and her supervisors. The videos are stored securely in compliance with HIPAA and will be permanently erased after 90 days. If you have any concerns about the recordings, please contact your therapist prior to your intake session. Please write your name in the blank space on the first line. Print and sign your name at the bottom of the page to provide permission for audio and video recordings.

Consent for Audio/Video Recording

Financial Statement

Psychological Services charges $25 per session. However, it is our mission to remove financial barriers to treatment. Therefore, we offer sliding scale fees for service, and you may indicate what you are able to pay with your therapist. Please complete as many of the questions on the form as possible. Print and sign your name on the second to last line.

Financial Statement

Notice to Consumers

Please read through the form. Your therapist will fill in the top portion for you at your intake session. Please write your name in the third to last line, sign on the “Signature of Patient” line and date it.

Notice to Mental Health Service Consumers

Notice of Private Practice

The Health Information Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed in any form, whether electronically, on paper, or orally are kept confidential.  Please read through the form.  Sign and date on the second page under “Receipt of Notice of Privacy Practices.”

HIPPA Information

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