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Francine Powel, Ph.D. Licensed Clinical Psychologist
 

Introduction
To assure that you are fully informed about the nature of your therapist's practice, to protect your confidentiality, and to access information that may be useful in making our time together most efficient, we are putting in this section downloadable copies of the forms most frequently used in our practice. Not all the forms will be relevant to your particular situation, but this will make them more available to you if/when you and your therapist together decide, for example, to request records from prior treatment or to communicate with a physician who might be prescribing medications. Of all the forms listed in this section, the only one we strongly encourage you to read before your first session is the Patient Therapist Agreement, so you have time to consider the information before you decide to proceed.You will need Adobe Acrobat Reader to download a printable copy of the form. If you do not have Adobe, just click on the link below to download and install.

Patient Therapist Agreement
This is the most important of the forms for you to read before your first session. We admit it is a long document, but we do want you to be fully informed of your rights as a patient, of steps we have taken to protect your personal information, and of policies concerning scheduling and fees. Federal law requires that we have made this information available to you, but our own view of the work we will be doing together depends on you being fully informed as well. Please read this document before your first session, and we will take time to discuss any questions or concerns you may have, and to know that you can raise questions at any time during the course of treatment.

Consent to Treat
After you have read the Patient Therapist Agreement, and discussed any questions you have with your therapist, she/he will ask you to sign the Consent to Treat, in which you and your therapist agree to abide by the terms of the Agreement.

Insurance Form
This is a single copy of the common insurance form that is used by most insurance companies. Completing this form assures that all the information that is required to process a claim on your behalf would be available. Your therapist will go over this form with you before you sign it, so you understand why we are requesting information. 

Personal History Form
This form allows your therapist to save some time in gathering information that is very useful in assessing issues currently facing you. We have found that asking you to complete this form, which includes a symptom checklist, will allow us to cover some areas more quickly, and to be sure that the issues that have brought you to therapy, or which affect your current issues will receive appropriate attention. Again, you and your therapist will discuss this form in the first session.

Primary Care Contact Authorization Form
If you permit it, we will work closely with your primary care provider, especially in situations in which you are taking medications as part of the treatment for which you have sought therapy. There may be other health related matters in which close collaboration with your physician will be helpful. Finally, some managed care plans, particularly HMO's, require that you have specifically permitted or specifically denied access to this information. Your access to treatment can not be made contingent on granting release of information, under ordinary circumstances.

Information Release Authorization Form
At times, you and your therapist may find it useful to seek records of past treatment, to discuss your situation with another party at your request, or to release our records to a professional you may be seeing after our treatment is concluded. In order to obtain or release your protected health information, you must fully understand what you are releasing, and the terms under which it can be released. Again, your therapist will go over this form with you if the occasion arises.

Children's Rights and Stipulation Form
We often see children in treatment whose parents are in process of separation, divorce, or litigation regarding the parenting plan subsequent to divorce. Children often are brought to treatment because of the effects of the parental conflict on them. Assessment and evaluation of custodial or access suitability is a highly specialized field, and we are not qualified to provide objective assessment in this area. Furthermore, children seeking treatment during this process must have a therapist whose only responsibility is providing treatment, not assessment of the adequacy of either parent or effects of contact with one parent or the other. Consequently, your child's therapist may ask each parent to sign this stipulation that the sole purpose of these sessions is for the treatment of the child, and that neither parent will request records or testimony from the therapist in any level of litigation between the parents.