Forms

Forms to Download Before Your First Visit

In transferring our forms to Google Docs, the formatting has been distorted (a common event when entering text on Mac OS at the time of this writing). Many pages have the signature portion on a second page, which needs to be included despite its brevity, just like any contract.

By downloading, printing, AND bringing the completed forms to your first visit, you will save yourself valuable time. If you do not bring completed forms to the first session, you will need to fill them out at the start of the session (this is state law).

Please do not send them back to me as a separate Google document to my email. A Hushmail account address can be given to you to send your PHI (personal health information) such as found in your forms in a HIPAA-compatible email (we are currently testing Hushmail for this purpose), but we prefer that you walk in or mail your information to our office.

For clients of Imei: You may also be given any additional forms as needed at the time of the visit related to insurance billing . Also, if you are using an approved form of insurance that SDC takes (Regence, Premera, UMP, First Choice), please bring your insurance card to your visit, or copy BOTH sides of the card onto one side of an 8.5 x 11 sheet of white paper.

Client Registration Form (one per person or couple/family)

Treatment Program Statement

Counselor and Fee Disclosure Statement

Use of Electronic Transmission Form (for mobile phone, email, and Wi-Fi video conferencing sessions). Providers and HR: if you would like to discuss how you can create your own ETF, please use my contact form to make a request.

Payment Form: As an office, we have chosen Square Register to handle your credit card or debit card payments. Unless you wish to set up a free Square Wallet account to pay for your visits (I highly recommend it!), we don’t keep any of your payment information on file.

If you wish to pay using Google Wallet, we also accept this as a way to pay for your session. You will need to set up your own account and attach it either to your bank or to a credit card.

We have received a chip reader for chip cards, and it is working properly. If you have a chip card, we would like to use the chip reader, and not the standard swipe reader, for your security.

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