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FORMS

After you have scheduled an appointment, please take a moment to complete the following forms PRIOR TO your first appointment and bring with you.
For privacy purposes, please do not scan or send via email. If you are unable to do so, forms will be provided for you at your first session.

NEW CLIENT INFORMATION

In an effort to maximize our time together in the office, please take a moment to complete and submit the following forms PRIOR TO your first appointment. If you are unable to do so, forms will be provided for you at your first session and we can fill them out together.

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NEW CLIENT INFORMATION (COUPLES)

In an effort to maximize our time together in the office, please take a moment to complete and submit the following forms PRIOR TO your first appointment. If you are unable to do so, forms will be provided for you at your first session and we can fill them out together.

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NEW CLIENT AGREEMENT

Please review all our policies to be sure you understand the binding nature of the therapeutic relationship and what you can expect from us, and what we expect from you. Under each category, please provide BOTH YOU AND/OR YOUR PARTNER’S INITIALS, to indicate that you have read through, understand and are in agreement with Wellness & Relationship Counseling.

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NOTICE OF PRIVACY PRACTICES (HIPPA)

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.

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CREDIT CARD

All merchant processing (credit card) is done through a secure app at the end of each business day. By signing this form, I authorize the office of Maureen DeLorenzo to charge all the applicable fees for services to the above listed card. This includes “late cancel” or “no show” charges per the signed client agreement.

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