One of each form needs to be completed prior to the appointment date and time or the appointment will be rescheduled.
The release of information is the only one not required, unless you wish me to share information with someone such as a spouse, family member, or individual who will be bringing the child.
All forms must be filled out and signed by a parent designated on the birth certificate or through a copy of the divorce decree provided at session to make such decisions.
Any child subject to a custody agreement must also bring a copy of the divorce decree prior to the appointment to be seen, Both parents will be contacted if there is joint custody in making medical decisions.
12321 Tierra Humeda
El Paso TX 79938
- Self-Assessment (filled out by the child over age 10 if they are the client)
- Client Information
- Policy for Emergency/Urgent Care
- Illness and Medical Problems
- Brief Medical History and Release
- Consent for Counseling
- Client Information and Office Policies
- Contact Preference and Office Policies
- Informed Consent to Teletherapy Consultation (only for telehealth sessions)
- Please Read Carefully & Thoroughly Part 2
- Notice of Privacy Practices
- Authorization to Disclose Protected Health Information (optional)
- Credit Card Form
- Fee Schedule Form