Below you will find links for all forms needed to start therapy at Healthy Synergy Psychological Services, LLC. Each form is in the common Adobe .pdf format and viewable using the free Adobe Reader (see below if you need to download Adobe Reader). Simply click on the form name to view the form. To make the most effective use of time during your first visit, please print and fill out the following five (5) forms before coming in. If you have any questions, feel free to call us or bring them with you on your first visit. Please do not sign anything that does not make sense to you. We will be glad to provide clarification for any of your questions or concerns.
Confidential Client Information Form: Please fill out all demographic information. If you are bringing your child to therapy, please be sure to fill out the parent/guardian information section. If you are the client and you are an adult, please disregard the parent/guardian information section. On the second page, fill out both the referral and physician releases of information if you would like these resources to be informed of your treatment with our agency.
Consent to Treatment: This form defines the parameters of treatment. Your signature on this form is required prior to the beginning of therapy.
Financial Agreement: This form defines the payment policies and procedures of our practice. Your signature is required on this form prior to the beginning of therapy.
Consent to Privacy Practices: Please sign this form to acknowledge that you have received a copy of the Notice of Privacy Practices (see below). Signature on this form is required prior to beginning therapy.
Notice of Privacy Practices: This is a detailed description of our privacy practices in accordance with the standards of HIPAA. There is nothing to sign on this form, but please retain a copy for your review.
Below, you can find any additional forms that you feel you may need prior to coming in.
Guide to Accessing Insurance Coverage: This is a guide for you to use while calling your insurance company to obtain information about your mental health benefits. It provides specific questions that you may want to ask your insurance company about your coverage.
Authorization to Release Information: This form is to filled out and signed if there are other individuals that you would like to be involved in your treatment, or others to whom you would like us to release information (e.g., school personnel, family members, other health providers). We may not release any information about your care with us without your signature acknowledging consent.
Credit Card Form: This form is utilized to place a credit card on file to pay for all copays and deductibles following your visits.