Forms

PART A

Please complete and print the appropriate form and bring it with you to your first appointment.*  

1. Minor Therapy Client Intake Form           

2. Minor Assessment Client Intake Form   

3. Adult Therapy Client Intake Form

 

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PART B 

Please complete and print the appropriate form and bring it with you to your first appointment.* 

1. Child Information Form

2. Adolescent Information Form

3. Adult Information Form

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PART C 

Please complete and print the following forms and bring them with you to your first appointment.*  

1. Consent for Treatment of a Minor Form (if appropriate)

2. Psychoeducational Testing Outpatient Services Contract

3. Psychotherapy Outpatient Service Contract

4. Acknowledgement of Receipt of Privacy Practices

5. HIPAA Notice of Privacy Practices Form (keep for your records)

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PART D

Dr. LaCost will tell you if you need to complete and print these forms at your first appointment.*

1. HIPAA Authorization Form

2. Authorization to Release Information

3. General Information Release Form

4. Questionnaire Authorization Form

 

 *NOTE: All forms require a username and password, which can be obtained from Dr. LaCost