Download Forms


 

Prior to coming in for your initial visit, please take a few minutes to download, print, complete and sign the forms provided below. You can either mail them to the office or bring them with you to your appointment. This will allow us to use our time together to focus on you and your goals. If you do decide to complete the forms at the office, please plan on arriving 20-30 minutes early to allow sufficient time to complete them.

In order to view and print the forms, you will need a free program called "Adobe Reader" (or equivalent software) installed on your computer. Most modern computers have this software pre-installed. Otherwise, you can visit www.adobe.com and download the free software.

Client information form - This form requests basic demographic information, contact information, and any emergency contacts you may have. Please complete the form before arriving for your initial evaluation.

Insurance Information - While I do not currently accept any insurance policies, and will not bill your insurance directly, having your insurance information on file will aid me in processing any prior authorizations for treatment or medications that may become necessary for your continued treatment. Please consult your insurance provider regarding their mental health benefits and their policies regarding out-of-network providers.

Treatment Consent Form - This form outlines my services, policies and procedures. By law, I am required to have your informed consent in order to treat you. Please review the terms listed in the document, sign, and bring with you to your first appointment.

Notice of Privacy Practices - I strongly support your right to privacy. This document outlines in detail my policies regarding the confidentiality of your sensitive health information. Please review it and keep a copy for your records

Acknowledgement Form - By signing this form, you indicate that you have received a copy of the Notice of Privacy Practices listed above.

Release of Information - I am a strong believer that collaboration between health care providers is key to providing effective care to our clients. If you are currently seeing another therapist, primary care physician or other health care professional, and would like us to coordinate care, or you would like me to have records from a previous psychiatrist or hospitalization to aid in forming your treatment plan, please fill out this form. Print and sign one form for each individual or facility to/from whom you would like me to release/obtain medical information.

Arbitration Agreement - My goal, of course, is to provide quality medical care to my clients in a way that will avoid disputes. Most problems occur as a result of miscommunication. So, if you have concerns about your medical care, please discuss them with me. 
This is a sample copy of the agreement you will be asked to sign at your initial visit. By signing the contract, we agree that any dispute arising out of the medical services you receive will be resolved in a binding arbitration before an arbitration panel rather than by a lawsuit in a court of law. This method of resolving disputes spares both parties some of the rigors of a court trial, and the publicity which may accompany judicial proceedings.

Location
OC-Psychiatrist, Inc.
26932 Oso Pkwy., Suite 200
Mission Viejo, CA 92691
Phone: 949-202-5266
Fax: 949-348-9626
Office Hours

Get in touch

949-202-5266