Licensed Psychologist

(410) 544-9564

FOR EVERYONE:

PLEASE CLICK ON THE ICON FOR EACH OF FORMS 1, 2, and 3.

SAVE EACH FORM TO YOUR COMPUTER . 
FILL OUT ALL 3 FORMS, 
PRINT THEM OUT, AND

BRING THEM TO YOUR FIRST APPOINTMENT   (if you prefer, you may let me know in advance to have the forms waiting for you to fill out before your first appointment, and you may arrive at least 15 minutes early to complete them)​

Thank you!
I look forward to getting to know you.

1. PERSONAL INFORMATION 



2. PRACTICE POLICIES AND FEE AGREEMENT 



3. INFORMED CONSENT TO PSYCHOTHERAPY  

Form # 4 is only if you are covered by Medicare:

I am "Opted Out", which means that you cannot submit claims to Medicare for reimbursement for my services. 
Medicare requires that you sign the following form agreeing to that.


   4. PRIVATE MEDICARE CONTRACT   



Form #5 is only if you wish or need to give consent
​for me to communicate with other providers

(for example, a psychiatrist, another psychologist, your physician)

   5.  RELEASE OF INFORMATION FORM   




Forms