Forms

Adult Intake Form

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

Adult Intake Form

Office Policies and Informed Consent

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

Office Policies and Informed Consent

HIPAA Notice of Privacy Practices

Describes how medical information may be used and disclosed

HIPAA Notice of Privacy Practices

Authorization to Release Information

Gives me permission to share information about our work with specific individuals or medical teams

Authorization to Release Information

Credit Card Authorization Agreement

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

Credit Card Authorization Agreement

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 Collaterals