FORMS INSTRUCTIONS - Completing these prior to your first appointment will save some time in the first session.
When you download the forms, your computer may alter the formatting some, so please feel free to adjust to optimize use of the paper. Please date the forms with the date of your first appointment. I look forward to working with you.
The 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.
The Privacy Notice is for your information only. No need to print.
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.
The Professional Disclosure Statement is for your information only. 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.
The face sheet document provides identifying information and the consent for the
communication with the insurance company, if that is applicable.
The 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.
The 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.
The 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.
The 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.
Eating Attitudes Test (EAT-26)
This form ONLY applies to those who have an appointment for Behavioral Health Evaluation in consideration for bariatric surgery.
Eating Habits and Description
This form ONLY applies to those who have an appointment for a Behavioral Health Evaluation in consideration for bariatric surgery.