Please 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.
Under Section 2799B-6 of the Public Health Service Act (Good Faith Estimate for Health Care Items and Services) individuals who are either uninsured (not enrolled in a plan or coverage or a Federal health care program) or self-pay (individuals who are enrolled in a plan or coverage or a Federal health care program but not seeking to file a claim with their plan or coverage) can request and be provided (orally and in writing) a good faith estimate of expected charges for items and services.
If a service is scheduled at least 10 business days in advance the Good Faith Estimate will be provided within 3 business days of scheduling. If a service is scheduled at least 3 business days in advance the Good Faith Estimate must be provided within 1 business day of scheduling. If a service is scheduled less than 3 business days in advance a Good Faith Estimate is not required. If an individual requests a Good Faith Estimate it must be provided within 3 business days.
NOTE : If you have United Healthcare/United Behavioral insurance there is an additional form for you to complete (listed under Other Miscellaneous Forms).
David's Forms - Marietta Office
David's Forms - McCaysville Office
David's NEW CLIENT Forms - MARIETTA OFFICE
NOTE: All 7 documents must be completed and received by the office via email at [email protected] or fax at 770-993-9800 at least twelve (12) hours before your scheduled appointment as confirmation of your intent to attend.
- New Client Information ( PDF fill-in form )
- Informed Consent
- Rights and Responsibilities
- HCFA (You only need to sign & date box 12 & sign box 13)
- Healthcare Professional Release
- Fee Schedule
- If using Insurance please include a copy of your insurance card. If using an EAP please provide the EAP company name, number and authorization number.
Other Miscellaneous 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.
David's NEW CLIENT Forms - McCAYSVILLE OFFICE
NOTE: All 7 documents must be completed and received by the office via email at [email protected] or fax at 770-993-9800 at least twelve (12) hours before your scheduled appointment as confirmation of your intent to attend.
- New Client Information ( PDF fill-in form )
- Informed Consent
- Rights and Responsibilities
- HCFA (You only need to sign & date box 12 & sign box 13)
- Healthcare Professional Release
- Fee Schedule
- If using Insurance please include a copy of your insurance card. If using an EAP please provide the EAP company name, number and authorization number.
Other Miscellaneous 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:
- Adobe Reader (for PDF files)
- OpenOffice (for DOC files)
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(Fillable PDF Form) |
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(You only need to sign & date Box 12 & sign Box 13) |
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This form is the "medical records privacy law" (HIPAA). You may print a copy and/or request a copy at your initial visit. |
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Please provide any information regarding current or prior medical and/or mental health treatments. |
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Sliding Fee Scale (Marietta Office) |
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Sliding Fee Scale (McCaysville Office) |