FORMS


Our paperwork is required to be filled out in full before your first scheduled appointment. It’s important for you to complete the paperwork before you arrive so you can spend your scheduled time with your clinician, not filling out forms. If you are not able to print these forms, we ask that you arrive no later than 30 minutes before your first appointment so that you have time to fill them out before your scheduled visit. When you schedule your first appointment, a member of our administrative staff can email you the specific forms you’ll need for your appointment.

Mental Health Counseling Forms

Weight Loss Surgery Patient Forms

Nutrition Forms

Notice Of Privacy Practices

  • Privacy Practices – Confidentiality is very important to us. We hope that you will read over this information to familiarize yourself with our policies that protect your private health information. You will find an acknowledgement of receipt for these practices in your packet listed above.

Other Forms

  • Release of Information (ROI) – To ensure our client’s confidentiality, protected health information is not shared without written consent from our client or their guardian (unless a client is deemed an immediate risk to self or others). This formed is used so that providers can communicate with one another via phone, fax, or email.
  • Rights & Consent to Treatment
  • Informed Consent for Tele-therapy – If your clinician indicates that you need this additional consent for tele-therapy sessions, they will inform you.

If there are any questions about these policies, please contact our Compliance Officer, Kendra Wilson or our Practice Manager, Sarah Snyder as appropriate.

* All materials contained in this Website are protected and may not be reproduced, republished, distributed, transmitted, displayed, broadcast or otherwise exploited in any manner without the express prior written permission of Chrysalis Center. You may download material (one copy per page) from this Website for your personal and non-commercial use only, without altering or removing any trademark, copyright or other notice from such material. Chrysalis Center’s names and logos and all related trademarks, trade names, and other intellectual property are the property of Chrysalis Center and cannot be used without its express prior written permission.


About Us

At Chrysalis, we believe that a supportive, healing environment is essential in order for change and growth to occur. We seek to offer such an environment to clients and help them create that in their lives and relationships. Read More

Hours

Mon: 8AM – 6PM
Tue: 8AM – 6PM
Wed: 8AM – 6PM
Thu: 8AM – 6PM
Fri: 8AM – 4PM
Sat: CLOSED
Sun: CLOSED

© 2019 Chrysalis Center | Design Interventions