Forms

For your convenience, the listed forms are available for you to complete, print, and bring with you to your first appointment.

All forms are in Adobe Acrobat format. This format allows users to print these files to any printer, using the Adobe Acrobat Reader program. Adobe Acrobat Reader is available at no cost for download from the "Get Acrobat Reader" button below.

General Information & Office Policies Agreement

General Information & Office Policies Agreement Form

Completion of this form allows Ms. Wakach to communicate with designated persons on behalf a client. Authorizations must be completely filled out and indicate the nature of the information to be obtained and/or released and for what purpose. (not required unless requested by Ms. Wakach).

General Information & Office Policies Agreement

Telemedicine Informed Consent Form

Completion of this form allows Ms. Wakach to communicate with designated persons on behalf a client. Authorizations must be completely filled out and indicate the nature of the information to be obtained and/or released and for what purpose. (not required unless requested by Ms. Wakach).

Authorization to Exchange Confidential Information Form

Authorization to Exchange Confidential Information Form

Completion of this form allows Ms. Wakach to communicate with designated persons on behalf a client. Authorizations must be completely filled out and indicate the nature of the information to be obtained and/or released and for what purpose. (not required unless requested by Ms. Wakach).

Health Insurance Portability and Accountability Act (HIPAA) Form

Health Insurance Portability and Accountability Act (HIPAA)

Review of Ms. Wakach's privacy practices and completion of an accompanying acknowledgment form is a requirement of federal law as it provides information about how your private medical information can be used or disseminated as well as how you can obtain said information. (required for all new adult and minor patients).

Adult Information Sheet

Adult Information Sheet

Please complete this form to provide more detailed information regarding reasons for seeking psychotherapy and demographic information used for billing purposes. (required for all new adult patients)

Adult Office Polices and Consent For Treatment

Adult Office Polices and Consent For Treatment

Please review and sign in acknowledgement that you agree to the terms of treatment. Your signature is written consent for services. (required for all new adult patients)

Minor Child Information Sheet

Minor Child Information Sheet

At least one parent must complete this form on behalf of their minor child providing detailed information regarding reasons for seeking psychotherapy and demographic information used for billing purposes (required for all new minor patients).

Minor Child Office Polices and Consent for Treatment

Minor Child Office Polices and Consent for Treatment

At least one parent must review and sign in acknowledgement that you agree to the terms of treatment for you minor child. Your signature is written consent for services. (required for all new minor patients).