Forms

This page contains forms used in our practice. The first file is the Application for Services in an Acrobat Portable Document format. The Application for Services contains spaces for your basic contact information, insurance and payment information (from your insurance card), signatures that are needed for insurance billing, and the informed consent for counseling services. We ask that you read the entire service agreement, print the first two pages out and fill them in by hand in order to bring them to the first appointment. This saves valuable session time, helps assure that you understand and feel comfortable with the practice policies, and allows for smoother billing procedures. Please read the entire Informed Consent document and be sure to ask about anything that causes questions or concerns before signing the consent. Please note that I only need the first two pages for my records; you should keep the last four pages of text for your reference.

Application_Consent_Full_Mar2013

The second file is the two-page Notice of Privacy Practices for Fitzgerald Counseling. All of the information you provide (verbal and written) is protected by HIPAA as well as by state and federal confidentiality laws. In general, no information is shared without your written consent, except in cases of legal mandate or risk of harm. Please read this notice, print out and sign a copy, and bring it with you to the first appointment.

HIPAA_NPP_2013

The following form explains issues of privacy and electronic payments if you use PayPal or credit cards to pay psychotherapy and counseling fees, including co-payments. You should read and sign this before using either of those payment methods.

Electronic Payments Communications Disclosure Form

Please feel free to send us a message if you have any questions about these forms.