patient service forms

Below are my clinical practice forms for psychotherapy services. Prior to our initial session, please be sure to review each document carefully, fill out the information, provide a signature and email all completed forms to my office.

drjleahy@jeanleahypsychologist.com

all emails are highly secure and encrypted

All documents can be easily filled out and signed using Adobe Acrobat Reader. After downloading document, open document with Adobe Acrobat Reader, then using the menu bar on top, next to the Home button, click Tools > Fill & Sign > Fill, sign, and send.

patient services agreement

Introduction to my practice, psychotherapy services, counseling process, appointment scheduling, professional fees, insurance and patient rights. Signature required.

Patient Information

Patient pre-session information form for psychotherapy or counseling, including related medical history.

E-Mail Policy and Contract

E-mail communication policy relating to counseling service. Permission election and signature required.

HIPAA - Notice of privacy practice

Your information, your rights, my responsibilities. Please review carefully. Signature required.

authorization for release of information

Permission for any of your listed providers to consult with me about your psychotherapy records and treatment. Signature required

informed consent for telepsychology

Informed consent for performing psychotherapy using the phone or the internet. Please read carefully. Signature required.

telepsychology emergency authorization

Emergency contact information including phone number and email address. Signature required.

patient treatment consent

Patient consent for treatment after reviewing all of my practice policies. Please read carefully. Signature required.

Good Faith Estimate

You are entitled to received this "Good Faith Estimate" of what the charges could be for psychotherapy services provided to you.