Application Form and Consent for Services (For New Scheduled Clients)

DO NOT fill out this form unless instructed by Dr. Fitzgerald. This form is only for current clients. If you are not a current client, your responses will be deleted.

Please do not sign this form until after we have scheduled an initial appointment. Once we have set up an initial appointment, you will need to complete and sign the form and consents on this page. You will not be considered a client until we have scheduled and kept an appointment. If you complete this form without an appointment scheduled, your responses will be deleted.

This page consists of the Application Form, Insurance Information, and Consent for Services (plus signatures for releasing claims information and assignment of benefits to Dr. Fitzgerald). These forms are secure and confidential.

After completing this form and prior to the first scheduled appointment, please also visit the “Notice of Privacy Practices” page and electronically sign that form. Also, If you will be using tele-health for sessions with Dr. Fitzgerald, an additional consent form is required, which explains the limitations and potential risks and benefits of using a secure tele-mental health platform. That is on the “Consent for Tele-Health Services” page in the upper menu.