| Alison C. Smith, Ph.D. Licensed Clinical Psychologist |
Forms & Downloads
PRIMARY FORMS
To facilitate the best use of our time during the initial session or
consultation, please download and complete the following before
your first appointment.
Client Contract: This document contains important information
about my professional services and business policies. It must be
reviewed and signed.
Confidential & Protected Health Information: This document
provides information about the rights and policies concerning your
records. It must be reviewed and signed.
New Client Form (Therapy): This form is for new clients who will
be attending therapy and is needed to provide me with basic
background information.
New Client Form (MHE):This form is for clients who are seeking a
Mental Health Evaluation and is NOT for therapy clients. This
document is needed to provide me with basic background
information. Please complete this form if you are getting a Mental
Health Evaluation.
Insurance Form: This document contains questions that you need
to ask your insurance company. One form contains questions
appropriate for individuals utilizing BCBS (Questions for BCBS)
and one that is appropriate for individuals utilizing out-of-network
benefits (Questions for Out-of-Network Benefits)
ADDITIONAL FORMS
Release of Information: If you would like me to speak to another
person regarding your case this form must be completed and signed.
People with whom you want me to be in contact may include
anyone ranging from another treatment provider, to an attorney, to a
close family member. Should I be contacted by someone regarding
your case for whom I do not have this authorization, my
commitment to confidentiality remains completely in tact and I will
not even acknowledge whether or not you are in treatment with me.
To facilitate the best use of our time during the initial session or
consultation, please download and complete the following before
your first appointment.
Client Contract: This document contains important information
about my professional services and business policies. It must be
reviewed and signed.
Confidential & Protected Health Information: This document
provides information about the rights and policies concerning your
records. It must be reviewed and signed.
New Client Form (Therapy): This form is for new clients who will
be attending therapy and is needed to provide me with basic
background information.
New Client Form (MHE):This form is for clients who are seeking a
Mental Health Evaluation and is NOT for therapy clients. This
document is needed to provide me with basic background
information. Please complete this form if you are getting a Mental
Health Evaluation.
Insurance Form: This document contains questions that you need
to ask your insurance company. One form contains questions
appropriate for individuals utilizing BCBS (Questions for BCBS)
and one that is appropriate for individuals utilizing out-of-network
benefits (Questions for Out-of-Network Benefits)
ADDITIONAL FORMS
Release of Information: If you would like me to speak to another
person regarding your case this form must be completed and signed.
People with whom you want me to be in contact may include
anyone ranging from another treatment provider, to an attorney, to a
close family member. Should I be contacted by someone regarding
your case for whom I do not have this authorization, my
commitment to confidentiality remains completely in tact and I will
not even acknowledge whether or not you are in treatment with me.
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