New Client Forms    

Welcome to my practice!

 

If this is the first time we are meeting and if you are a Cigna, Medicare and Out-of-Network patient, please review my privacy of information policies and complete and sign the new client forms below. Please bring these forms to your first appointment. If you are not able to download and print the forms, plan on arriving 20mn early to your first appointment. (Lyra Health clients, please visit the Lyra Health tab.)

Adults​ (Cigna, Medicare, Out of Network only)

  • Consent to treatment

  • Third party payer information

  • Personal history (adult version)

 

Adolescents (12-17) (Cigna, Medicare, Out of Network only)

  • Consent to treatment (signed by legal guardians and teens age 14 and above on separate documents)

  • Third party payer information

  • Personal history (adolescent version)

 

© 2015 Datchi Psychology and Consulting, LLC

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