Forms

The following forms and handouts are in PDF format. You may fill out the form online and print OR you may print the form and fill it out by hand. For your FIRST VISIT, you will need the First Appointment Intake Form, a Fee Agreement Form, and a HIPPA Privacy Notice Form. If you want your doctor to discuss your treatment with anyone such as a family member or a family physician then you will also need to complete a Consent Form.  If you don’t wish to fill out initial paperwork ahead of time it only takes a few minutes prior to your scheduled first visit.

(Click on the link to view the PDF)

Welcome – Outline of general practice information and office policy

First Appointment Intake form – basic information form for first visit.

Fee Agreement Form – Agreement explaining fees and specifying how you plan to pay for services.

HIPAA Privacy Notice Form – This form explains how your private health information may be used and explains some of our office policies.

Consent to Release Information Form  – This form gives permission to release records or speak to someone, such as your family doctor. No information is ever released without written, signed, permission to do so. The form allows you to specify the exact information you would like released or discussed.

Gottman.17-Areas.Scale Optional Questionnaire for couples entering couple counseling

Marital.packet –  Optional Second packet of questionnaires for couples entering couple counseling