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Patient Forms for Your First Therapy Session

To ensure that your first therapy session goes smoothly, we require all new clients to complete a set of patient forms before their initial appointment. This allows us to better understand your needs and ensure we’re fully prepared to support you.

Forms for All New Patients

All new clients, regardless of their background or reason for seeking therapy, need to read and electronically sign the following forms prior to their first appointment:

  • Consent for Treatment: By signing this form, you acknowledge that you understand the nature of the therapy process and consent to receive treatment.
Review Consent for Treatment Form

If you prefer, you may print and sign the PDF version of this form, and return it to us via email at info@griefrelieftherapy.com prior to your appointment.

  • Credit Card Authorization Agreement: This form authorizes Grief Relief, LLC to use your credit or debit card. We will only collect card information verbally over the phone or in person.
Review Credit Card Authorization Agreement
  • No Show/Late Cancellation Policy Form: By signing this form, you acknowledge that you have read, understand, and agree to the No-show/Cancellation Policy as defined in this document provided by Grief Relief, LLC.
Review No Show/Late Cancellation Policy Form

Specialized Forms for First Responders

At Grief Relief, LLC, we offer specialized support for first responders, recognizing the unique challenges they face. If you are a first responder and are using the On the Job and Off’s FRAP, please read and electronically sign the Credit Card Authorization Agreement, No Show/Late Cancellation Policy form, and the following forms prior to your first appointment:

  • First Responder Assistance Program (FRAP) Consent for Treatment: By signing this form, you acknowledge that you understand the nature of the therapy process and consent to receive treatment.
Review FRAP Consent for Treatment Form
  • First Responder Assistance Program (FRAP) Release of Information: This form authorizes Grief Relief, LLC to disclose to and receive information as defined in this document. Note: A witness signature is required at the end of this form.
Review FRAP Release of Information Form

Other Forms

  • Release of Information: This form is for you to specify who and give us permission to communicate with others regarding your information with Grief Relief, LLC. Note: Please only complete these after you’ve had a conversation with your therapist about waiving your right to confidentiality.
Review Release of Information Form
  • Non-Covered Services Agreement: Please read and electronically sign this document only if office staff has directed you to do so.
Review Non-Covered Services Agreement Form
  • 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.
Review Medical Records Request Form

How to Submit Your Forms

Please download, print, and complete the appropriate forms before your first appointment. You can complete them via the linked Google Forms above or arrive early to your appointment to complete them in person.

If you have any questions about the forms or need help completing them, don’t hesitate to contact our office at 717-522-6111. We’re here to make this process as easy as possible for you.