Lori Payne, Licensed Professional Counselor
Find hope in the journey...
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Forms
The following forms will need to be completed prior to the initial assessment (the HIPAA Notice & Notice of Confidentiality are yours to keep). Lori has made them available as Word documents that you may print and fill out prior to the assessment if you wish. If there are questions about any information on the forms, Lori encourages you to bring those questions to the assessment. She will spend the first 5-10 minutes of your assessment reviewing the Intake/Consent process with you.
Client Information:
NHC_ClientInformation.doc
Parent Information:
NHC_Parent_Family_Info.doc
__________________________________________________________________
Intake/Consent for Services:
NHC_IntakeConsentForSvcs.doc
Notice of confidentiality:
NHC_Notice_of_Confidentiality.doc
HIPAA Notice:
NHC_HIPAA.doc
HIPAA Signature Page:
NHC_HIPAA_SignaturePage.doc
Credit Card Information Release:
NHC_CreditCardInfo.docx
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