Forms


For new clients

The links below bring up forms that we will need to initiate counseling.

Consent for Treatment

This form tells my qualifications, explains your rights, and lays out our financial agreements. Please read, print, sign, and bring to our first appointment.

Client History Form

This form ensures that I have relevant information about you, your personal history, and your family history—all information that helps us to plan and implement your treatment. Please fill out completely, print, and either email to me 24 hours before our first appointment or bring with you to the appointment.

HIPPA Privacy Policies

This form indicates legal requirements for confidentiality of information about you and your treatment, including limitations on who information may be shared with (e.g., insurers and other practitioners) and requirements for such sharing. Please read, print, sign, and bring to your first appointment.

HCFA-1500

If your treatment will be covered by your insurance, and if I am a provider for your insurer, then please fill out the client data portions of this form so that I can file claims on your behalf. This form is not needed for self paying clients or those who pay in full and then personally file insurance reim­burse­ment claims. Please fill out, print, and either bring to your first appointment or email to me.

Email

Email address: beth@bethobrienphd.com (this link opens your email application)