Use TherapyPortal to electronically access and sign your documents, as well as check your appointment time.
Psychotherapy Intake Form
Complete this form and return it to us before 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 email Meghan A. Marty, PhD, Privacy Officer, Rose City Geropsychology, LLC at firstname.lastname@example.org.
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