BOULDER PSYCHOLOGIST

ANXIETY SPECIALIST

Forms

Paperwork may be completed at first meeting (Please arrive 15 minutes early if you chose this option) or you may download, print, and complete in advance. Please be aware this practice no longer bills insurance. You can leave insurance information section blank on the first page of the registration form.

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. (You can leave insurance information section blank.)
  2. All patients complete the Disclosure Statement and Informed Consent Form and sign the appropriate signature page (adult or child). Please note that teens, age 15 and over, must sign in addition to parent signature.
  3. Complete either Adult History or Child/Family History form.
  4. Electronic Payment Authorization form to be completed.
  5. Last page of HIPPA notice to be signed.
  6. Release of information only needed if you want Dr. Scatigno to share information with other providers or individuals involved in treatment.

Please don’t hesitate to ask any questions regarding this paperwork.

Child/ Adolescent Packet Forms

Registration Form (You can leave insurance section blank), Child History Form, Financial Letter and Electronic Payment Authorization, and  Disclosure Agreement and Informed Consent.

Adult Packet Forms

Registration Form (You can leave insurance section blank), Adult History Form, Financial Letter and Electronic Payment Authorization, and Disclosure Agreement and Informed Consent.

HIPPA Notice of Privacy Rights (only last page needs to be signed)

Release Exchange of Information Form (Complete this form only if you want me to discuss treatment with anyone else)

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

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I respect your privacy. Your name and email address will never be shared with third parties.