FIRST SESSION FORMS
PLEASE NOTE:
If you have questions about the First Session Forms I will be happy to discuss them with you during our initial appointment.
• Consent for Services (required)
Please provide information and signatures of both parents/legal guardians if your child is under 18 years old.
• Telepsychology Informed Consent (required)
Please provide information and signatures .
• HIPAA Notice and Receipt (required)
Please provide information and signatures on separate "receipts" for each person that will be meeting with Dr. Stroup.
• Client Contact (required)
Please complete separate forms for each person that will be meeting with Dr. Stroup.
• Adult Information (required for clients 18 years old or older)
Please complete if you are a client over 18 years old.
• Child Information (required for clients under age 18)
Please complete for any child client under 18 years old.
• Payment Agreement (required)
Please provide information and signatures of both parents/legal guardians if your child is under 18 years old.
• Privileged Communications Agreement (required for clients under age 18)
Please provide information and signature of both parents or legal guardians.
• Credit Card Authorization (optional)
Authorization for credit card charges for professional services using Squareup.
• Release of Information (optional)
Authorization for release of information to specified parties (i.e physicians, spouses, etc.)