Patient Forms
New Patient Forms
Please complete PRIOR TO YOUR FIRST APPOINTMENT
Consent for Treatment
Please read and electronically sign this document PRIOR TO YOUR FIRST APPOINTMENT.
If you prefer, you may print and sign the PDF version of this form, and return it to us prior to your appointment.
By my signature, I acknowledge that I have read, understand, and agree to the policies and procedures of outpatient treatment as defined in this document provided by Grief Relief, LLC.
Credit Card Authorization Agreement
Please read and electronically sign this document PRIOR TO YOUR FIRST APPOINTMENT.
By my signature, I acknowledge that I have read, understand, and agree to the Credit Card Authorization Agreement as defined in this document provided by Grief Relief, LLC.
No Show/Late Cancellation Policy
Please read and electronically sign this document PRIOR TO YOUR FIRST APPOINTMENT.
By my signature, I acknowledge that I have read, understand, and agree to the No-show/Cancellation Policy as defined in this document provided by Grief Relief, LLC.
Non-Covered Services Agreement
Please read and electronically sign this document ONLY IF OFFICE STAFF HAS DIRECTED YOU TO.
By my signature, I acknowledge that I have read, understand, and agree to the non-covered services agreement as defined in this document provided by Grief Relief, LLC.
Existing Patient Forms
ONLY complete after you've had a conversation with your therapist about waiving your right to confidentiality
Release of Information
Please read and electronically sign this document for anyone you want us to be able to communicate with regarding your information with Grief Relief, LLC.
By my signature, I do hereby consent to, and authorize Grief Relief, LLC to disclose to and receive information as defined in this document provided by Grief Relief, LLC.
Medical Records Request Form
This form is used to request copies of medical records. Only patients or their legal representatives may make a medical record request. Some requests may be subject to a reasonable fee.
By my signature, I do hereby consent and authorize Grief Relief, LLC to release copies of my medical records to the provided entity as defined in this document provided by Grief Relief, LLC.