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FIRST SESSION FORMS

 

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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.

 

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.)