FORMS

The following forms may be downloaded for completion prior to the first appointment:

Health Information Portability and Accountability Act

HIPAA the standard for protecting sensitive patient data.

HIPAA Notice of Privacy Policies

This HIPPA notice describes how medical information about you may be used and disclosed. It also explains how you can get access to this information.DOWNLOAD HIPAA FORM

Disclosure Statement & Consent for Testing

Client rights and important information.

Disclosure Statement & Consent for Testing

You are entitled to receive information from the psychologist about the different evaluation procedures, the techniques used, the duration of the evaluation, and the fee structure.DOWNLOAD CONSENT FORM

Consent for Confidential Communication

How to request information.

Consent for Confidential Communication

HIPPAA gives you the right to request financial and/or medical information in confidence by your chosen method(s), which can include telephone, postal mail, or e-mail.DOWNLOAD COMMUNICATION FORM

Release/Exchange of Information

Authorization to exchange information.

Release/Exchange of Information

Authorize Dr. Katherine Bellon to disclose mental health treatment information and records obtained in the course of psychotherapy treatment/evaluation.DOWNLOAD RELEASE FORM

Developmental History Questionnaire

Complete regarding your child’s early medical and developmental history.

Developmental History Questionnaire

Please fill out this information to the best of your ability and bring to your first appointment.DOWNLOAD QUESTIONNAIRE

COVID-19 Consent Form

Informed consent for in-person services during the COVID-19 public health crisis.

COVID-19 Consent Form

Contains important information about our decision to resume in-person services in light of the COVID-19 public health crisis.DOWNLOAD CONSENT FORM

Credit Card Authorization Form

Credit Card Authorization Form

If you choose to pay by credit card, you will be charged according to the agreed upon schedule.DOWNLOAD CREDIT CARD FORM