Forms

Intake paperwork will be emailed to you after your intake appointment has been confirmed. Please email the packet back to me or bring it with you to the first appointment. This practice does not bill insurance. You may request a monthly superbill. I cannot provide services to anyone who has Medicaid, per regulations. If you obtain medicaid coverage during the course of your treatment, you are required to inform me and unfortunately, we would need to terminate services.

You will need Adobe Acrobat Reader to download and open these files. You can get it free by clicking here if you don’t already have it on your computer.

Instructions:

1. All patients complete Registration form.
2. All patients complete the Disclosure Statement and Informed Consent Form and sign the signature page.
3. Please note that children, age 12 and over, must sign in addition to parent signature.
4. Complete Personal History or Child/Family History form.
5. Electronic Payment Authorization form to be completed to store a card on file.
6. Last page of HIPPA notice to be signed.
7. Release of information only needed if you want Dr. Scatigno to share information with other providers or individuals involved in treatment.
8. If utilizing telemental health services, complete specific telehealth informed consent form for video conferencing.

Please don’t hesitate to ask any questions.

24 hours notice of cancellation is required. You will be charged for the time reserved for your appointment.

Payment is due on the date of service. A credit or HSA card can be stored on file for your convenience.

Child/ Adolescent Intake Packet Forms: Will be emailed to you.

Adult Intake Packet Forms: Will be emailed to you.

HIPPA Notice of Privacy Rights(Please sign last page)

Release/ Exchange of Information Form(This form is needed if you request that I collaborate with school staff or other medical or behavioral health care providers)

Social Media Policy(Please read this. Consent form indicates you have read this policy