Forms

The following forms can be completed prior to your first visit.

HIPPA Consent

This form outlines your privacy rights regarding your protected health information:

 

MENTAL HEALTH BENEFITS FORM

This form should be used to contact your insurance company and verify benefits prior to your first visit

 

Application Form

 

Credit Card Billing Authorization Form 

This form can be used if you choose to charge your fees to a credit card or Medical Saving account

 

Statement of Financial Responsibility

This form outlines our financial policies and your responsibility.  Please sign a copy for us and keep a copy for your records.