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Couple Therapy Session

Forms & Policies

To simplify the check in process the following intake forms have been provided for each clinician. After reading the policies detailed below, please scroll down to your provider's name to download and complete all relevant forms listed. Then bring them with you along with your insurance card (if using) and form of payment to your first appointment.

CANCELLATION POLICY
When you schedule an appointment with your provider, we reserve that time specifically for you and plan for as well as prepare for our aniticipated work together. If you are unable to make any appointment, please notify us as soon as possible so we can make other arrangements either with you or with another client who would like your time slot.

Like any other medical appointment, we respectfully request 48 hours notice of any appointment cancellation. This advanced notice is necessary in order for us to make other arrangements and prepare for different appointments. Each of us has our own set fees but we each require 48 hour notice for cancellations to avoid being charged a no show or late cancellation fee.

NOTICE OF PRIVACY PRACTICES: This is a very important HIPAA related form that informs you about your Protected Health Information, what it can be used for with and without your permission and your rights regarding accessing your records held by your provider. Please be sure to read that information found on our Confidentiality & Privacy Practices page.

INTAKE FORMS:

BILL ROEDEL, PH.D.

Disclosure Statement - Service Agreement

Client Billing Information & Authorization Form

 

General Release of Information Form  (This form is helpful when there is another person involved in your care.)
 

Biographical Information Form (This form must be completed on-line and will take approximately 20 minutes to complete. To complete the form, you will need the login name and password you selected or were given when you made your appointment.)

TERRI BUYSSE, Ph.D.

Disclosure Statment - Service Agreement

Client Billing Information & Authorization Form

Adult Biographical and Life Stress Questionnaire

Child Biographical Information Form        

Client Information and First Session Details                                          

General Release of Information Form (This form is helpful when you have more than one professional involved in your care.)

Warrior Mom (Please complete this form if you are a new mom, up to 18 months postpartum, even if this is not your first child, and you are experiencing exaggerated or uncharacterisitc anxiety, depression or anger/rage - or feel like your are "loosing it" in any way.)


RANDIE CLARK, MA, LMHC

Disclosure Statement - Service Agreement

Client Billing Information & Authorization Form

Biographical Information Form (This form must be completed on-line and will take approximately 20 minutes to complete. To access the form, you will need the login name and password you selected or were given when you made your appointment.)

General Release of Information Form (This form is helpful when you have more than one professional involved in your care.)

SUSA HOLT, ND, MA, LMHCA, SEP

Disclosure Statment - Service Agreement

Client Billing Information & AuthorizationForm

Biographical Information Form (This form must be completed on-line and will take approximately 20 minutes to complete. To access the form, you will need the login name and password you selected or were given when you made your appointment.)

General Release of Information Form (This form is helpful when you have more than one professional involved in your care.)


DORALISSA GRIFFIN, MS, LMHC

Disclosure Statement - Service Agreement

Client Billing Information & Authorization Form

Biographical Information Form (This form must be completed on-line and will take approximately 20 minutes to complete. You will also need the login name and password you selected or were given when you made your appointment.)

General Release of Information Form (This form is helpful when you have more than one professional involved in your care.)

JENNIFER BERRY, MSW, LICSW

Disclosure Statement - Service Agreement

Client Billing Information & Authorization Form

General Release of Information Form (This form is helpful when you have more than one professional involved in your care.)

Biographical Information Form (This form must be completed on-line and will take approximately 20 minutes to complete. To access the form you will need the login name and password you selected or were given when you made your appointment.)

JULIE HANSON, Psy.D., LMHC

Disclosure Statement - Service Agreement

Client Billing Information & AuthorizationForm

Biographical Information Form (This form must be completed on-line and will take approximately 20 minutes to complete. To access the form you will need the login name and password you selected or were given when you made your appointment.)

General Release of Information Form (This form is helpful when you have more than one professional involved in your care.)