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NEW PATIENT FORMS

Please print and complete forms. Email all forms to officedr.rap@gmail.com or fax to 858-400-5204 at least 24 hours prior to your appointment..

Below are forms for New Patients. Please read carefully so you know what to complete:


ALL New Patients must complete the Forms (1-6) below, as well as the appropriate History form, and return them to the office (email or fax) prior to your appointment

1. Patient Information (PDF)
2. Practice Guidelines (PDF)
3. Privacy Statement (PDF)
4. Email and Social Media Communication (PDF)
5. Credit Authorization(PDF)
6. Telehealth Consent Form(PDF)


If a child/teen is to be seen, parent/guardian please complete:

Child History (PDF) (12 and Under)


Teen/Young Adult History (PDF) (Age 13-20 : to be completed by TEEN/YOUNG ADULT)


If Adult is to be seen in therapy, please complete:

Adult History (PDF)



OTHER FORMS:

TO GIVE PERMISSION FOR DR. RAPPAPORT TO SPEAK WITH SOMEONE REGARDING YOU OR YOUR CHILD, PLEASE COMPLETE THE RELEASE OF INFORMATION FORM BELOW.

Release of Information (PDF)



 


© Copyright 2020 Lori Rappaport, PhD. All rights reserved