Forms

Forms to Download Before Your First Visit

In transferring our forms to Google Docs, the formatting has been changed. 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 or completing the electronic file (NEW!), send the completed forms before your first online session.  By Washington State law, we cannot conduct your session without  signed consent and contact information.

Please do not send them back  as a separate Google document to my email. A ShareFile account address will be given to you to send your PHI (personal health information); alternatively, you will be given an address to send your paperwork if you prefer to use snail mail. ShareFile is a HIPAA compatible file sharing and storing platform.

If you’d like to preview the Client Guide from Citrix on how to upload and download your forms to me securely, here’s a link from the Citrix ShareFile that explains how to do this. Don’t worry: I (Imei) will walk you through it.

For clients of Imei: You may also be given and requested of any additional information 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), photograph 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.

If you prefer not to receive your forms via ShareFile, they are available below for you to download and mail to a secure P.O. Box.

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 Cash to handle your credit card or debit card payments, and Square Invoices to handle HSA and FSA payments.  We do not keep any of your payment information on file.