Human brain, psychiatric symptoms

Forms

We use a secure third party service where you can get all patient forms. Links provided below.

GENERAL FORMS
ALL PATIENT FORMS

NEW CLIENT FORM
ACKNOWLEDGEMENTS
CONSENT TO TREATMENT
MEDICATION REFILL REQUEST
NOTICE OF PRIVACY PRACTICES
OUT OF NETWORK CLAIM FILING AGREEMENT
RELEASE OF INFORMATION

SELF-EVALUATION FORMS
PHQ-9
GAD-7
EPWORTH SLEEPINESS SCALE
ADULT ADHD SELF-REPORT SCALE

ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL

Clinical information is kept either physically secure or on a secure, encrypted web server which is compliant with U.S. federal health information technology standards (HIPAA)

Absolute confidentiality is assured. Information is only shared under the following circumstances:

  1. Under the client’s direction & written consent
  2. For the coordination of emergency health care where obtaining proper consent is either impossible or would cause such a delay that harm would ensue
  3. To guard against imminent danger to the safety of an adult or child
  4. Under the direct order of a judge or court

For more information, download our complete privacy policy, above.

  • Currently we are fully booked and regrettably unable to accept new patients except in certain cases via referral.

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