Forms and Documents

Psychotherapy & Counseling with Heather Roselaren, LCSW/MPH

Forms & Documents

As we've probably discussed, there's quite a bit of initial paperwork we'll need to get through before the end of your first session. I'm really sorry, but that's just the way it is in the current healthcare system.

If you fill out as many parts as possible of the applicable documents before you arrive, we can spend more of the session time talking about your priorities and use less of it for the paperwork.

Please download the documents that apply to you, print them, fill them out, and bring them with you to your first appointment (or send them to me several days before as noted). Feel free to save a copy for your records as well.

If and When I Need It	Document (click or double click to view)

Information I Need Several Days Before Your First Appointment If You're Paying with Insurance	Advance Insurance Questions

Documents You Must Sign Before or During the First Appointment	How Things Work in My Practice (basic policies)
	Policy for Regular and Missed Appointments (changes and mixups)
	Privacy Practices Notice (“HIPPA notice”)

Documents That Need Information from You Before or At Your First Appointment	Client Information Sheet (your basic contact and insurance information)
	Email Reminder Options (what type of reminders you want, if any)
	Consent to Treat (your permission for me to treat you)
	Consent to Treat Minor (your permission for me to treat your child. if your child is the client)
	Consent to Release Medical Information (to your doctor or other provider)
	Consent to Release Information to Your Referrer (to the office or person who referred you, if any)

Other Documents To Fill Out Before or At Your First Appointment If You're Using Insurance or Someone Else is Paying Your Fees	Insurance Information Sheet (basic information about your insurance)
	Responsibility for Payment Changes (when and what you need to tell me)
	Consent to Release Payment Information (if insurance or another person is paying part of your fees)