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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. These six (6) forms may be downloaded from the links below or filled out at your initial session.  Please bring the completed forms, along with your insurance card, to your initial session.

NOTE: 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.   

ADDITIONAL NOTE: If you have United Healthcare/United Behavioral insurance coverage there is additonal information for you to complete.  You will find these specific forms listed below.


New Client Forms


United Healthcare/United Behavioral Wellness Form


Optional Forms

  • 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.
  • Consent for Adults (18 and Up)
  • Consent for 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
 
HFCA
(You only need to sign & date Box 12 & sign Box 13)
Fee Schedule  
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.
Healthcare Professional Release Form
Please provide any information regarding current or prior medical and/or mental health treatments.
Sliding Fee Scale  

Helpful Forms

Click here to view and print forms for your appointment.

CLICK HERE