Brian J. Smith, Psy.D.
Please follow the directions below to download and complete the appropriate forms prior to our initial appointment. Please bring them with you and I will review them briefly at the beginning of our first session. Thank you!
Adults need to complete the following forms:
1. Client Face Sheet 2. HIPAA Information & Signature Page* 3. Professional Services Agreement & Signature Page* 4. Adult Client Information Form 5. Medication Record
*If you'd like to save paper, I only need the signature pages of the HIPAA Information packet and Professional Services Agreement.
*For couples, please 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 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:
1. Client Face Sheet 2. HIPAA Information & Signature Page 3. Professional Services Agreement & Signature Page 4. Child & Adolescent Developmental History Form 5. Medication Record
*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.