Client Forms

New clients will need to fill out several forms before therapy can begin. To make the process as smooth and efficient as possible, Loving Families provides the most important documents as downloads right here on the website.

 

Please download and return the completed documents to our practice either in person or as a scanned PDF file via e-mail. 

If you are unsure which forms to fill out, please submit your questions via the Contact Form.

REQUIRED FORM - Disclosure Statement
This form must be completed by all new clients.
For minors (under the age of 12) this form must be completed by ALL parents with medical decision making custody. Please provide documentation if you possess full medical decision making custody for a minor.
Disclosure Statement Final.pdf
Adobe Acrobat document [167.8 KB]
REQUIRED FORM - HIPAA
This form must be completed by all new clients.
HIPAA Final (1).pdf
Adobe Acrobat document [136.1 KB]
REQUIRED FORM - Consent to Communicate PHI Electronically
This form must be completed by all new clients.
Consent to Communicate PHI Electronicall[...]
Adobe Acrobat document [99.7 KB]
OPTIONAL FORM - Credit Card Authorization
All clients who wish to use a credit card as a payment form must complete this form.
Credit Card Authorization.pdf
Adobe Acrobat document [36.9 KB]
OPTIONAL FORM - Authorization to Release Information
This form must be completed before Loving Families can contact any third party on the client's behalf. (ie: School Staff, Lawyer, Child Care, Extended Family)
Authorization to Release Information.pdf
Adobe Acrobat document [107.6 KB]
OPTIONAL FORM - Informed Consent For Electronic Psychotherapy
This form must be completed before Loving Families can engage in telehealth sessions on doxy.me.
Informed Consent for Electronic Psychoth[...]
Adobe Acrobat document [110.2 KB]

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