Forms
Please fill out all forms in the 14-page packet below. The first page "Client Data Sheet" is required so I may contact you. The following pages are the "Disclosure Statement" and the "Finacial Statement". Page 4 is the "Schedule of Additional Fees" and the following page will cover the "Practice Policy and Procedures" and "Financial Responsibility". These require your signature and include your rights and responsibilities if you need me in court, for depositions. Page 6 goes over our HIPAA Policy. The "Patient Easy Pay Plan and Consent" is required for all clients, including EAP. It is only used when you authorize me to use it (as for a copay) or for a no-show. Most insurances and EAPs do not pay for no-shows, so you are responsible for them. Page 8 and 9, "Ground Rules for Therapy" is a social contract between you and me and we each get a copy. The last five pages are a questionnaire and are optional, but I strongly recommend you fill them out as it will shorten the therapy work. I always read them. Thank you and I look forward to our collaboration.
2. For the best way to fill the following form out, make sure you have the latest Adobe Acrobat Reader here: https://get.adobe.com/reader/
3. After filling out, please save and send the finished form to: mikezelman1@gmail.com