Forms
Forms for Clients
- Intake Form
- Intake Form part 2
- HIPAA Notice of Privacy Practices: By law I am required to provide this notice to you so that you can understand your rights to privacy and how your health information is protected.
- Receipt of HIPAA Notice: Please download, print and sign this document to acknowledge that you have received the HIPAA notice.
- Authorization to release information: I am unable to discuss information about you without your written authorization, except for situations described in the HIPAA notice. This is the form we would use if you and I both agree that it would be useful for me to communicate with other people involved in your care, such as your primary care physician, a prescribing physician, or a former therapist.
For ValueOptions insurance members only:
- ValueOptions Members Rights: I am required by ValueOptions to provide you with this handout on your rights.
- Receipt of ValueOptions Members Rights: Please download, print and sign this document to acknowledge that you have received the ValueOptions Members Rights notice.
- Release of information to insurance company: Please download, print and sign this document acknowledging that I will be communicating with your insurance company.