FORMS
Intake & Signature Documents
After your initial appointment has been confirmed by phone or email, please, download and complete the Intake Forms in the corresponding hyperlink below. These forms must be completed and turned in at your first appointment. You must also bring a legal proof of identification with a photograph (e.g., driver’s license) and your insurance card (if you will be using insurance) to our first meeting. Parent/guardian ID is sufficient for children and adolescents.
Good Faith Estimate (GFE) Notice & No Surprises Act (NSA)
The Behavioral Change Clinic, PLLC is committed to keeping you informed of your rights and being transparent about all costs associated with its psychological services. The Good Faith Estimate (GFE) Notice informs you of your rights.
Notice of Privacy Practices (NPP) & HIPAA
The Behavioral Change Clinic, PLLC is committed to safeguarding your information regarding your physical health, mental health, and personal history. The protections and limits of confidentiality are listed in the below documents. A version of them that requires your signature is included in the intake documents above. They are provided here for your convenience and empowerment.
Release Form
If you wish for your Therapist to communicate with someone, please download, print, and complete the release form. Most commonly, this is used to allow consultation with a physician, psychiatrist, former therapist, school counselor, or stepparent. Release forms are usually optional.
Right to Paper Copies
If you make a written request, The Clinic will provide you with any signed documents that you have completed.
Telemedicine
If you wish to engage in telemedicine (i.e., telehealth via real-time, interactive audio and/or video), please go to the telemedicine webpage to learn more and download the form. You will still need to have completed the intake and signature documents above.