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Woman Being Free

Client Forms

 

If you are a new client, please print out the following forms, complete them and bring them to your first session.

If the new client is a minor, please print out the following form and bring it with you as well.

If you wil be receiving services from your therapist via interactive video, please print out the following form, sign it, and return it to your therapist:

This is the HIPAA Indiana Notice regarding Protection and Privacy of Health Information. We follow these policies and procedures at Feathergill and Associates.  Please review this form and present any questions you may have to your therapist in your first appointment, or at any time you have concerns about the pricacy of your health information.

HIPAA Indiana Protected Health Information Form

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form:

 

 

 

Note: To download Adobe Acrobat Reader for free, click here.

 

 

Helpful Forms

Click here to view and print forms for your appointment.

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