Before we meet each other through telepsychology for the first time, you will need to register as a client who is seeking a first appointment. During this first session, you will explore the possibility of working with me as your psychotherapist and counselor. Among other questions, I will ask you about your concerns and goals. You may ask me any questions you may have.
In order to register, you can download and fill out the forms below, then mail them to me at 2020 West 86th St., Suite 301, Indianapolis, IN 46260. I will also need a copy of your drivers license or some other method of identification as well as a copy of your insurance card (front and back), if you are using insurance. If you can't or do not wish to download some or all of the relevant forms, I can mail them to you. Please be aware that unencrypted email is not entirely secure, and I do not want our communication to go through that method. Please call me at 317-872-4158 if clarification is needed at any point.
If you are coming with your spouse for marital therapy, only one of you needs to register as the identified patient.Upon receiving your completed registration materials, I will sign them myself if a witness is needed and then contact you by phone to set up a session. How you will access me for this session is included in the Informed Consent for Telepsychology in the list below.
If your insurance company requires authorization for outpatient mental health services, it is important that you call them and get the authorization before our first appointment.
- Demographic Data - I will need to know the medications you are taking. For example, Celexa 20 mg twice daily. You can put them on this form or send a separate list. "About the Insured" means the holder of the policy, which may not be the patient. Your social security number is not mandatory but may be needed for ID.
- Consent for Mental Health Services - If you want other people with whom you have personal relationships to be able to get information about you from me, do include their names. If you want a spouse, for example, to participate in couple's therapy sessions with you, specifying the name on this form is necessary.
- Services Agreement - For telepsychology, payments for which the client is responsible will be expected by check at end of the month for ongoing treatment. If sessions should occur in-person, payment as described in this Service Agreement will be expected.
- Physician Communication Form - If you want me to exchange information with any physician except a psychiatrist (for whom there is a special form below), please fill out and sign this form. If you do not authorize the exchange, please sign and check Option B to refuse.
- Health Insurance Claim Form- If you do use insurance, please fill out the top part of the Claim Form through boxes 12 and 13, each of which are to be signed.
- Informed Consent for Telepsychology - This form describes, among other issues, how to access the telepsychology platform we will use, doxy.me. This video conferencing platform is recommended by the Indiana Psychology Association and is compliant with HIPPA guidelines, insurance industry requirements, and Indiana Law. At the time of your appointment or a little before, you will enter the URL link on the Informed Consent form into your browser and sign in with your name. I will be signaled that you are available. I will then finalize the connection, enabling our video and audio communication at the time of our appointment.
HIPAA Privacy Notice
. This Notice is for your information and does not have to be sent back to me. There is also more information on the
Privacy and Policy
As said before, if you and your spouse are interested in marital therapy, only one of you will register as the patient. The identified patient's spouse will need to include the other spouse on the Consent for Mental Health Services Form. In addition, there are two more forms. The Outpatient Services Agreement for Collaterals Form is to be read and signed by the non-patient spouse. Both spouses are are to read and sign the Informed Consent for Spouses Form to protect the couple's therapy from possible legal proceedings.
If you would like me to coordinate care with another mental health provider (for example a psychiatrist or a previous therapist), complete this form to authorize release of Protected Health Information:
Again, if there are questions about the registration, please call me at 317-872-4158.
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