Of course you knew paperwork would be involved! Don't worry though. I have assembled
all of the necessary forms and documents in this one convenient location.
Please read, sign and bring this paper work with you on our first appointment.
These documents are available in two formats.
Microsoft Word
and as web page
Face Sheet
This form is used to collect information about your insurance for billing purposes.
Disclosure Statement
The disclosure statement provides information about my education, experience and therapeutic orientation.
Privacy Standards
This statement is issued in order to comply with the Health Insurance Portability and Accounting Act of 1996
(HIPPA).
Payment Agreement and Insurance Authorization
The payment agreement is our contract to provide therapy in return for payment from you and your insurance providers.
Intake Questionnaire
The Intake Questionnaire provides me with information about you and gives us a place to explore your therapeutic
interests. If you are covered under EAP benefits, there is no need to fill out this form.
Copyright 2003 Deartherapist.com | page last updated : July 14, 2003
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