NOTE: ALL new patients will need to complete the two PDFs under "Intake Paperwork", and the one PDF under "Telehealth Consent". Other forms are on an as-needed basis.
Intake Paperwork
All new patients should fill these two out, and the "Telehealth Consent" form! Please print and complete all needed paperwork prior to your first appointment. Please bring paperwork and your insurance card with you to the appointment.
| New Patient Paperwork |
| Procedure and Fees |
Telehealth Consent
All new patients should fill this out, and the "Intake Paperwork" forms! Also, any patients who have not filled one out and would like to try telehealth, please send a copy of this to Jenny's assistant. As we've found in Covid-19 times, sometimes appointments need to be online for safety.
| Telehealth Consent |
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties
Parents
If there are multiple parents / guardians who will be involved in a child's care, each one should fill this out. Please fill out the below form and have all parents (custodial or non-custodial) sign and have witnessed. There is already a copy of this included in the Intake Paperwork packet, this sheet is primarily for additional parents / guardians.
| Parental Agreement for Confidentiality |
Authorization
This form is for patients on an as-needed basis. Click here to download an authorization for us to communicate with a third party if you would like me to do so. If this is a case which has a Guardian ad Litem involved, it is often helpful for you to sign this authorization at the beginning of therapy. There may be other healthcare practitioners or family members that you would also like me to communicate with.
| authorization_release_form-revised.docx.pdf |
