Privacy Practices and Forms

Confidentiality:

Confidentiality is very important to us and we hope you will read our Privacy Practices to familiarize yourself with our policies.

In each intake packet, there is an Acknowledgement of Receipt that must be signed indicating that you have read our Privacy Practices. You may print out and/or read our Privacy Practices but do not need to bring that to your appointment; it is yours to refer to as needed.

Intake Forms:

Please print out the appropriate Intake Forms for the type of service you will be pursuing. 

If your parent or guardian will be  providing payment, the Third Party Payer Agreement forms will also need to be filled out and brought to your first session.

General Forms

Bariatric Surgery Pre-Op Evaluation Forms

Eating Disorder Forms

Nutrition Only Forms

Couples Forms  - packet must be filled out by both parties

Financial Forms:

Third Party Payer Agreement

Office Procedures and Financial Agreement

Other Forms:

Client Update/Change of Insurance - We ask our clients to update this every six months. Please feel free to print it out and bring it with you to your appointment as needed.  If your insurance policy changes, you will also be asked to fill this form out.

Release of Information/Request for Information - All areas must be filled out prior to signing and a letter with the client or legal guardian's signature detailing the requested information must also be provided.

Note: A PDF viewer is required to view these files.