New Client Forms

After reviewing, completing and signing the following forms, please send them, along with clear scans (or clear photos) of the front and back of your insurance card(s), to chaitanyabilling@yahoo.com

The Basic Client Information Form – download and complete (Word Document)

The Client Demographic and Information Form – download, complete and sign (Word Document)

After reviewing the HIPAA Notice of Privacy Practices (PDF) and the Informed Consent for Telepsychology (PDF) documents, please download, complete and sign the Combined Signature and Acknowledgement Page (Word Document).

Note: the forms you are asked to complete, sign and return are in MS Word format. You can type your information directly onto the Word document, save and send it to us as a Word or PDF attachment.

In order to type directly into Word, you must enable the “overtype” function:
   1. If the Word document opens in PROTECTED VIEW, click Enable Editing
   2. Click File/Options/Advanced
   3. Select Use Overtype Mode under Editing Options