Forms

Please complete all REQUIRED FORMS and return as an attachment to heather@drheatherstone.com

Required Forms

• Patient Information Form
  Complete and sign hard copy, or open in Acrobat for prompts.
• Notice of Privacy Practices
  Review, sign, and return signature page if acceptable.
• Consent for Psychotherapy Services
  Review, sign, and return signature page if acceptable.
• Consent to use email or text
  Please review, sign, and return form.
• Payment-Authorization
  Please complete if you wish to pay with credit card.
• Telemedicine Informed Consent
  Please complete if you wish to use interactive audio or video conferencing as a venue for psychotherapy.

Optional Forms

• Authorization to Release Information
  Optional: Please add third party (e.g. other medical provider), sign, and return form.
• Authorization to Release — Collateral
  Optional: Please add collateral — supportive person(s), sign, and return form.
• Psychotherapy Collateral Agreement
  Required with form above: Collateral participants should read, sign and return this form…
•  Medicare Opt-Out Form
  Optional: Please sign and return form.