The following forms are provided for your convenience. Please complete them prior to our first appointment. This will allow us to spend more time during our first session on discussing your goals and expectations for our work together, rather than on completing paperwork. If you're a first-time client, please review and complete the following forms, bring them to your first session.
This form provides information about our services, fees, billing and confidentiality. Please read and initial all sections and sign on last page. Feel free to discuss any questions you have regarding the content of this document during our first session.
- HIPAA Privacy Notifications
This form is for your information. It provides an explanation regarding the use and storage of your private information by Newport Beach Family Therapy where I practice.
This form provides various automatic payment options for your convenience so that you may get the most out of our time together without having to spend time from our sessions to take care of payment of services.
Please complete the top section of page one of this document.
If you would like to use your insurance benefit to cover a portion of the cost of counseling, please complete the top section of this document and sign the sections regarding authorization to release information and authorization for payment to provider, located just above the provider section of the form. Please note, that you remain responsible for any portion not covered by your insurance benefit. Also, please bring your insurance member ID card with you and we will make a copy of it for your file.
You can download the following forms:
Note: To download Adobe Acrobat Reader for free, click here.
|
Client Consent Form