New Patient/Intake Forms

New Patient Instructions

Please call our office to schedule an initial appointment.   Before your appointment, call your insurance company to check on your mental health benefits.  You will want to know before you come in if your insurance will cover part of your visit.     Be sure to ask who manages the mental health benefits, because it may be different from the insurance plan listed on your card. If we are not providers for your insurance, find out if you have any out-of-network benefits.  If you do not, you will have to pay the full cost of services.

Please note that if we are out-of-network, you will have to pay our self-pay rates at the time of service and file claims with your insurance company.  We will give you an insurance receipt.  They will reimburse you based on their fee schedule, which may be less than ours.  You should ask the following questions and be prepared to provide this information at your intake appointment:   

1) What is my copayment? 2) Do I have to have a deductible to meet before my insurance company will start paying?  If so, how much is it and has it been met?  3) Do I need preauthorization? This is no longer required for most mental health plans.  4) Is there a limit to how many sessions I can have?   Write down the name of the person you spoke with and the date.  You may need this in case of problems.

Be sure to bring your insurance card to your first appointment.  The secretary will need to make a copy of the card.  If you (or your child) has had prior psychological testing, please bring copies of these reports to the first appointment for the therapist to review.  If you (or your child) has had prior therapy or been prescribed psychiatric medication, it would help us greatly if you can provide us with the names (and addresses or phone numbers if you have them) of prior therapists.   We will need you to sign a release of information so we can contact them should the need arise.   

Please arrive 5-10 minutes early for your first appointment to give the secretary a chance to check you in, copy your insurance card and driver’s license (for identification purposes), and have you sign a financial agreement, as well as other paperwork if you have not printed out and signed them ahead of time.  If you complete the HIPAA forms ahead of time, PLEASE read our HIPAA policies carefully, as they contain important information about the limits of confidentiality.  This form must be signed before your therapist sees you .  Be sure to ask your therapist if you have any questions about confidentiality, particularly if you are bringing your child or teenager in.    For more information on HIPAA, check out the US HHS website for health privacy information.

Intake Forms

Please print out and complete the following intake forms.  They are all in PDF format.  This will save you time at the initial appointment.  Complete the Child and Adolescent History Form if you are bringing your child or teen in for treatment.  Complete the Adult History Form if you are an adult coming in for treatment. If you have copies of previous evaluations, please bring them with you.

Be sure to print out our Office Procedures, which will help you understand how we operate and help make your experience with us a positive one.

For the Release of Information form, please print one out for each person you would like us to contact.  Insurance companies require us to ask that you sign a release for your primary care physician, though you can check the “do not authorize” line if you do not want your therapist to contact your physician.

Financial Agreement                                

Patient Registration Form