Forms

Thank you for contacting me to address some of the issues that are concerning you.

Before our first session, it is necessary to read over and complete the initial paperwork. In this packet, you will find important information regarding the scope of services, as well as information about confidentiality and payment.

Please take the time to fill out this information and bring it with you to your first visit.

The packets above have the following forms enclosed:

  • Client Information and History Form: This provides information about you, your current concerns, and history.
  • Consent and Psychological Services Agreement: This form indicates that you are voluntarily seeking services and what therapy entails. Please review, initial each point, and sign at the bottom.
  • Health Insurance & Consent Form (for clients using insurance): Please complete as much information as possible
  • Payment Contract for Services: This form can be completed during our first session. It covers what the approximate rate of each session is (if you are paying out of pocket) or what your portion of out of pocket payment is (if you are utilizing insurance as well as benefits from your insurance company).
  • The Notice of Mental Health Practitioner’s Policies & Privacy Practices to Protect the Privacy of Your Health Information (HIPAA): This form is standard for any healthcare provider and is required by HIPAA law. It discusses your protected health information (PHI). Please keep the three pages of the HIPAA policy for your records (pages 7-9 in this packet).

Please bring your Driver’s License or valid picture ID and Insurance Card to our first appointment so a copy can be made for your record.

I will be happy to discuss any questions that you may have during our first session.

Thank you,

Tina DiCicco Reynolds, Psy.D.
Licensed Clinical Psychologist
PY 7384