Forms for New Clients
Please bring to your first appointment:
- Intake Form
- Intake Questionnaire
- Receipt of HIPAA Notice
- HIPAA Notice of Privacy Practices: (For your information – Read or download if you wish.) By law I am required to provide this notice to you so that you can understand your rights to privacy and how your health information is protected. (Updated January 2015)
For Stanford students who will be using CardinalCare/MHN insurance:
For ValueOptions insurance members:
- Receipt of ValueOptions Members Rights
- Release of information to insurance company
- ValueOptions Members Rights (For your information – Please read; download if you wish.) I am required by ValueOptions to provide you with this handout on your rights.
- Authorization to release information: I am unable to discuss information about you without your written authorization, except for situations described in the HIPAA notice. This is the form we would use if you and I both agree that it would be useful for me to communicate with other people involved in your care, such as your primary care physician, your psychiatrist, or a former therapist.
- Questionnaires At times I may ask you to fill out these questionnaires.