FORMS INSTRUCTIONS - Completing these prior to your first appointment will save some time in the first session.
To print forms and complete by hand, please click the title of the form.
Forms can be completed online and directly submitted (my preference) by clicking link at the end of the form description. This process is encrypted and HIPAA compliant.
I look forward to working with you.
Forms can be completed online and directly submitted (my preference) by clicking link at the end of the form description. This process is encrypted and HIPAA compliant.
I look forward to working with you.
Emergency InstructionsThe Emergency Contact form is for your information only. If you are currently in a crisis, please present to an Emergency Room nearest you for assistance.
|
Facesheet/ Release for InsuranceThe face sheet document provides identifying information and the consent for the
communication with the insurance company, if that is applicable. Link for online completion/ submission: forms.myupdox.com/form/59591 |
Privacy Practice Notice/ HIPAAThe Privacy Notice is for your information only. No need to print.
Bill of Rights and Responsibilities
The Bill of Rights and Responsibilities is for your information only. No need to print.
Discharge Process Policy
The Discharge Process Policy is for your information only. No need to print. Electronic Communication Policy
The Electronic Communication Policy is for your information only. No need to print. Professional DisclosureThe Professional Disclosure Statement is for your information only. No need to print.
Good Faith Estimate Notice
Required notification of fees for self-pay and/or uninsured clients. No need to print. Telehealth Services Policy and Consent
If you desire telehealth services, please read the policy and consent closely and inquire for more information. You will need to print and complete the consent. Only print if using telehealth services - otherwise, this form is not applicable. Link for online completion/ submission: forms.myupdox.com/form/59592 |
Counseling AgreementThe counseling agreement will serve as the informed consent for treatment.
Where there are choices to be made, please initial in the blanks to indicate your choice. Your signature is required at the end. Link for online completion/ submission: forms.myupdox.com/form/59593 Psychosocial/ IntakeThe Psychosocial Form provides some background information and you may write on the back if there is not enough room. If you you do not understand what I am
asking or if you just want to wait to talk about some of this, it is fine to leave it blank. Link for online completion/ submission: forms.myupdox.com/form/59658 Patient Health QuestionnaireThe PHQ is an evidence based health screening form that I would appreciate your
completing. It will assist me in knowing how to best help you. Link for online completion/ submission: forms.myupdox.com/form/61162 Outcome Questionnaire 45.2The OQ45 is another screening instrument that gives me some information about
your symptoms. Please complete this form the day of or day before your first appointment and answer as to how you have been feeling in the last few days. Link for online completion/ submission: forms.myupdox.com/form/61166 Eating Habits and Description
This form ONLY applies to those who have an appointment for a Behavioral Health Evaluation in consideration for bariatric surgery. Link for online completion/ submission: forms.myupdox.com/form/59841 |
