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

• General Intake
• Couples Intake (This packet must be completed separately by each partner)
• Eating Disorder Intake
• Child & Adolescent Intake

Bariatric Surgery Patient Forms

• Pre-Operative Psychological Evaluation
• Post-Operative Nutrition Assessment

Nutrition Forms

• Nutrition Intake

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

• COVID Informed Consent
• 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.
• Informed Consent for Parents/Guardians – if the client is under 18 years old, this will need to be completed by a parent or guardian.
• Informed Consent for In-Office Visits Post-COVID – when we return to the office, this form details your rights and responsibilities, as well as Chrysalis’s, to protect from communicable diseases.

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

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