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Blue Mountains
Blue Mountains

David's Forms

If you're a first-time client, you will need to print and complete the New Client Forms.  Please select and complete the forms for the location you are scheduled (Marietta or McCaysville).  These forms may be downloaded and completed from the links below or completed at the office at the time of your appointment.  Please bring the completed forms (if applicable), along with your insurance card, to your initial session.

If you are divorced from your child's other parent, please provide a copy of the Divorce decree and/or a copy of the Custody agreement so that assurance of all appropriate consents are available at the initiation of the counseling relationship.

NOTE: If you have United Healthcare/United Behavioral insurance there is an additonal form for you to complete (listed under Other Forms).
 

 

New Client Forms - Marietta Office

Other Forms

  • United Healthcare/United Behavioral Wellness Form - This form is to be completed if you have UHC/UBH insurance.
  • Adults (18 and up)
  • Minors (under 18)
  • Consent / Release of Information - This form is to be completed if you are requesting that I communicate (via phone, fax, email, etc.) with someone (without your presence) including family members, spouse/partner, or other professionals.
  • Adults (18 and up)
  • Minors (under 18)
  • Privacy Notice - This form is the "medical records privacy law" (i.e. HIPAA).  You may print a copy for your records and/or request a copy at your initial visit.
  • Sliding Fee Scale - For clients who either do not have insurance coverage or want to self-pay.

 

New Client Forms - McCaysville Office

Other Forms

  • United Healthcare/United Behavioral Wellness Form - This form is to be completed if you have UHC/UBH insurance.
  • Adults (18 and up)
  • Minors (under 18)
  • Consent / Release of Information - This form is to be completed if you are requesting that I communicate (via phone, fax, email, etc.) with someone (without your presence) including family members, spouse/partner, or other professionals.
  • Adults (18 and up)
  • Minors (under 18)
  • Privacy Notice - This form is the "medical records privacy law" (i.e. HIPAA).  You may print a copy for your records and/or request a copy at your initial visit.
  • Sliding Fee Scale - For clients who either do not have insurance coverage or want to self-pay.


NOTE: If you need any programs to view the forms, they are free to download at the following links:

New Client Information (Word Doc Form)
New Client Information (Fillable PDF Form)
Informed Consent  
Rights & Responsibilities  
HCFA (You only need to sign & date Box 12 & sign Box 13)
Fee Schedule  
Privacy Notice This form is the "medical records privacy law" (HIPAA). You may print a copy and/or request a copy at your initial visit.
Healthcare Professional Release Please provide any information regarding current or prior medical and/or mental health treatments.
Sliding Fee Scale (Marietta)

 Sliding Fee Scale (Marietta Office)

Sliding Fee Scale (McCaysville)  Sliding Fee Scale (McCaysville Office)
Helpful Forms

Click here to view and print forms for your appointment.

CLICK HERE