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PLEASE PRINT AND COMPLETE FORMS AND BRING THEM WITH YOU TO YOUR INITIAL VISIT.

NEW PATIENT FORMS

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

ALL New Patients must complete forms A,B, C,and D for first appointment.

A. Patient Information (PDF)
B. Practice Guidelines (PDF)
C. Privacy Statement (PDF)
D. Email and Social Media Communication (PDF)

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

E. Adult History (PDF)

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

F. Child History (PDF)

For Teens/Young adults (13-20) being seen in therapy, please complete:
G. Teen/Young Adult History (PDF) (NOTE: to be completed by TEEN/YOUNG ADULT)
OTHER FORMS:
If you would like to pay with a credit card, please complete form H.

H. Credit Authorization(PDF)(optional)

I. Release of Information (PDF)

If you are seeing Dr. Mary DeWitt, please complete this form  
J. Informed Consent(PDF)

 


© Copyright 2016 Dr. Lori Rappaport Ph.D. All rights reserved