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Blue Mountains
Blue Mountains

Helpful Forms

Before your/your child's initial evaluation, I will need you to fill out, sign, date, and send in (by mail,  email, fax or carrier pigeon) the following:

Background Information Form (not required if you are transferring from Tri-County)

The Treatment Agreement is a required form that specifies policies related to payment, confidentiality, cancellations, and much more. There are separate forms for treatment agreement for minors and treatment agreement for adults

Please read the Notice of Privacy Practices and sign the acknowledgement.  

Release of Information authorizations for any current or recent mental health providers, your pediatrician or primary care doctor, and your school.  Each person or organization gets their own form.  Children 14 and over should also sign the release of information forms.

The Release of Information documents will need to be re-authorized with your signature annually

I will scan and upload the completed documents into your/your child's medical record.

Disclaimer: The information on this website is intended for your information and education. It is NOT to be used as specific medical advice for you. I will be happy to discuss your particular, individual situation with you if you decide to become a patient.


Helpful Forms

Click here to view and print forms for your appointment.