Practice Information & Consent to Treatment

This form contains detailed information about my practice, including information about appointments, fees & insurance, and cancellation policy. Your signature on this form lets me know that you understand the policies of my practice and that you agree to enter into treatment with me under these conditions.


Notice of Privacy Practices

This form lets you know how medical information about you may be used or disclosed, and how you can get access to this information. It is similar to the notice of privacy practices that you receive from your primary care physician. 


Consent to Use & Disclose Your Health Information

Your signature on this form lets me know that you have read my Notice of Privacy Practices (see form above) and that you agree to let me use your protected health information and to send it to others for the following purposes:

  • To decide on what treatment is best for you and to provide treatment to you
  • To arrange payment for your treatment
  • To help carry out certain business or government functions
  • To help provide other treatment to you

Agreement to Pay for Professional Services

Your signature on this form means that you agree to pay for the services I provide to you.


Client Basic Information Form

This form gives me basic information about you, so that I will know how to contact you and have other information that I need for administrative purposes.


All Intake Forms

All of the forms above can be downloaded in a single PDF file here.

 

77 Franklin Street, Suite 809 • Boston, Massachusetts 02110
781.591.2584