Psychotherapy Intake Form

Complete this form and bring it with you to your first session

Office Policies and Informed Consent

Describes important information about the professional services and business policies of Rose City Geropsychology, LLC

HIPAA Notice of Privacy Practices

Describes how medical information may be used and disclosed

Note: you have the right to request access to your medical records. To do so, please make your request in writing, with your signature, and mail it to Meghan A. Marty, PhD, Privacy Officer, Rose City Geropsychology, LLC, P.O. Box 86816, Portland, OR 97286-0816.

Authorization to Release Information

Gives us permission to share information about your psychotherapy with specific individuals or medical providers

Credit Card Authorization Agreement

Allows us to charge your credit card for services not covered by your insurance, such as co-pays/co-insurance, late cancellations, or no-shows

Informed Consent for Collaterals

Describes the role and responsibilities of another person whom we may invite to participate in your treatment, such as a spouse, family member, or friend

Informed Consent for Telehealth

Describes benefits and risks of using telehealth for remote psychotherapy sessions

Informed Consent for In-person Services During COVID-19

Describes safety procedures and expectations for meeting in-person during the COVID-19 pandemic

No Surprises Act Standard Notice