New Patient Forms

Welcome, you are one step closer to your journey with me. The new patient forms below are an important part of this process.

If you are a new patient, please click on each of the links below and fill out the required fields and be sure to sign the form if indicated. Once you click the submit button, the forms will be sent to my inbox on Updox for me to review.

PATIENT
INFORMATION & TREATMENT AGREEMENT FORM

This form includes demographic, insurance and other important information to meet your needs.  It also provides you with policies and other information relevant to your treatment and care.  Please review this form in detail.

TELEHEALTH
CONSENT FORM

This form is to provide you with an option of a confidential, virtual setting to better meet your needs.  Time constraints and transportation issues may affect your ability to meet in person, however your access to care will not be affected.

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

This form empowers you with a choice of who is most important to include in your care. This form can be revoked at any time and is current for only one year and will need to be signed on an annual basis.  It may be recommended from time to time to call your primary provider (doctor) to discuss some medical findings or changes in your care. This is an example of how to use this form.  There can be only one provider/person on each form. Please complete a separate form for each provider, therapist or family/friend you want to be a part of your care.  Please cut and paste the form as needed.  Please complete this form

PATIENT HISTORY
FORM

This form is a place to tell your story, past and present with mental illness. What is your goal with meeting with me?  What treatments have worked, what has not worked?  How do you feel about taking medication? What are your concerns or fears about this journey? Please take the time to tell your story.  Share what you are comfortable with sharing.  This will provide insight on how to best meet your needs. This form will be reviewed prior to your appointment. 

CREDIT CARD
AUTHORIZATION FORM

This form is required to be kept on file for all patients. This information will be used to pay for fees at the time of the appointment including copays.

Screening Tools

GAD-7

This form is a screening tool to provide information on your level of anxiety over the past two weeks. You may be asked to complete this over the course of your treatment if it becomes relevant.

DEPRESSION SCREENING

This form is a screening tool to provide information on your level of depression over the past two weeks. You may be asked to complete this over the course of your treatment if it becomes relevant.