Brian J. Smith, Psy.D.

Licensed Psychologist

Client Forms

Please follow the directions below to download and complete the appropriate forms prior to our initial telemental health  appointment. Please send the forms with the asterisk to [email protected] after we schedule and appointment. You will send the rest of the forms directly to me once I schedule you.

Adults need to send in the following forms and items:

1. Client Face Sheet* 2. Photo of front and back of insurance card (if going through insurance)* 3. Photo of driver's license* 4. Credit Card Authorization Form* 5. HIPAA Information & Signature Page 6. Professional Services Agreement & Signature Page 7. Adult Client Information Form 8. Medication Record 9. Informed Consent for Telemental Health


*Please send these forms to [email protected] and the rest of the forms directly to me.

If you'd like to save paper, I only need the signature pages of the HIPAA Information packet and Professional Services Agreement.

Couples, please complete the same forms for Adults above with the following additional directions. Complete the client face sheet indicating which one of you will be the client in name (if going through insurance, please consider whose insurance you will be using), complete the HIPAA and Professional Services Agreement signature pages  and Informed Consent for Telemental Health form jointly, and then complete individual copies of the Adult Client Information Form and Medication record.

For Children and Teenagers under 18, please complete the following forms:

If you'd like to save paper, I only need the signature pages of the HIPAA Information packet and Professional Services Agreement.1. Client Face Sheet* 2. Photo of front and back of insurance card (if going through insurance)* 3. Photo of driver's license (of parent or guardian)*  4. Credit Card Authorization Form* 5. HIPAA Information & Signature Page 6. Professional Services Agreement & Signature Page 7. Child & Adolescent Developmental History Form 8. Medication Record 9. Informed Consent for Telemental Health 


*Please email these forms to [email protected] and the rest of the forms directly to me.


If you'd like to save paper, I only need the signature pages of the HIPAA Information packet and Professional Services Agreement.

If you need me to release, receive or share information with another individual (e.g., psychiatrist, psychologist, therapist, pediatrician, school representative), please also complete the below Release of Information Form.

Client Face Sheet

HIPAA Information & Signature Page

Professional Services Agreement & Signature Page

Adult Client Information Form

Child & Adolescent Developmental History Form

Credit Card Authorization Form

Release of Information Form

Informed Consent for Telemental Health