- P: 424.229.1838
- F: 310.399.9358
You will need to review these forms, and if you have questions please bring them up when we first meet.
Patient Agreement: My Patient Agreement Form explains my office procedures and agreement for psychotherapy services. You will be able to access this at any point in the future simply by downloading it from my website.
HIPAA Notice of Privacy Practices: am required by law to provide you with a copy of the HIPPA Notice of Privacy Practices so you can understand your rights and protections related to the use and disclosure of your identifiable health care information. You will be able to access this at any point in the future simply by downloading it from my website.
Background and History Form: Before our first session, please complete my Background and History Form and bring it to our first appointment.
Acknowledgment of Notifications Forms: Once you have read my Patient Agreement Form , and the HIPAA Notice of Privacy Practice Form , please sign my Acknowledgement of Notifications Form. This states that you have access to and have read all forms. Bring this to our first session.
Thought Record: Sometimes in our work together we may use a Thought Record sheet, you can download them here.
Sleep Diary: If we are meeting about Sleep Issues or Insomnia Issues, then you can download a 7-day sleep tracker here.
Consent To Release Authorization: There may be times when you and I agree it would be helpful for me to speak with another person to coordinate your care. With the exception of the situations outlined in the HIPAA form, I cannot do this without your written consent. Usually, we will speak about this in person and you will sign the form in my office. However, if you’re unable to meet with me, you may complete my Consent To Release Authorization and send it back to me.
Before our first session, please complete my Background and History Form and bring it to our first appointment.
I am required by law to provide you with a copy of the HIPPA Notice of Privacy Practices so you can understand your rights and protections related to the use and disclosure of your identifiable health care information. You will be able to access this at any point in the future simply by downloading it from my website.
My Patient Agreement Form explains my office procedures and agreement for psychotherapy services. You will be able to access this at any point in the future simply by downloading it from my website.
Once you have read my Patient Agreement Form, and the HIPAA Notice of Privacy Practice Form, please sign my Acknowledgement of Notifications Form. This states that you have access to and have read all forms. Bring this to our first session.
There may be times when you and I agree it would be helpful for me to speak with another person to coordinate your care. With the exception of the situations outlined in the HIPAA form, I cannot do this without your written consent. Usually, we will speak about this in person and you will sign the form in my office. However, if you’re unable to meet with me, you may complete my Consent To Release Authorization and send it back to me.
If we are meeting about Sleep Issues, or Insomnia Issues, then you can download a 7-day sleep tracker here.
This is a Thought Record sheet which we will sometimes use in our work together, it can be especially useful if you have a tendency to ruminate or perseverate on thoughts. You can download this for your own use, but it is not necessary to fill out as a new patient.
