If you are a new client, please complete the following forms. Print them out, sign them, and scan them to return by FAX (866) 540-3094, or email to your therapist. All forms are required to begin therapy. Thank you!
- Client Information Form
- Consent to Treatment Form
- Consent to Fees and Billing Procedures
- Consent to Electronic Communications
- Telehealth Informed Consent Form
- Tell Us About Yourself Questionnaire
- Credit Card Authorization Form
For potential clients of Dr. Len Hickman: Thank you for taking the time to complete the three following questionnaires. Your responses will help determine if I am likely to be of therapeutic assistance to you. Your responses will be kept in a confidential file and will be destroyed if you do not become a therapy client of Feathergilll and Associates.
If the new client is a minor, please print out the following form and bring it with you as well.
If you would like to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), require your medical records for another matter, or would like a copy of your healthcare records complete this form:
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.
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