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James J. De Santis, Ph.D. Post Office Box 894, Glendora, CA 91740-0894 (818) 551-1714 The reader is welcome to print any screen from this website for personal use only as long as author, copyright, and contact information are not removed. Over the years, we have received many requests from our colleagues for our office forms. Our forms are now available for purchase. Who Will Benefit? This kit may be a both quick and useful system for those who are: - Newly licensed and wanting to enter practice - Re-entering private practice after time away - Shifting from the public sector to private practice - Successful practitioners wanting to update their materials The forms in this kit are expressly designed for outpatient mental health services. Ethical and Thorough These forms have been carefully developed during a period of over 10 years with attention paid to detail. The text has been drafted with the intent toward achieving the spirit of informed consent, quality of patient care, and principles of professional ethics. These forms have been heavily field-tested and are frequently updated based on changes in practice, law, and ethics in the mental health field. We receive many compliments on the professional quality of the materials, both wording and format. Modular Format The architecture of this kit is modular so that components may be flexibly assembled based on the needs of the particular situation, whether for psychotherapy or psychological testing; whether for cash pay, indemnity insurance, or managed care arrangements; whether for adults or youth. Customizable The digitalized version can be custom-edited using most word-processor software packages. The forms can be modified for use by different disciplines, including psychologists, clinical social workers, marriage & family therapists, and professional counselors, or for different state requirements. List of Forms Patient Intake Patient Information Information About Service Treatment Agreement Testing Agreement Group Therapy Agreement Telehealth Agreement HIPAA Notice of Privacy Practices HIPAA Consent HIPAA Disclosure Log Specialized Consents Release of Information Coordination of Care with Primary Care Physician Coordination of Care Between Health Care Providers Financial Agreements Financial Agreement Acceptance of Patient Financial Responsibility Consent to Bill Third-Party Payor Third-Party Payor Verification Indemnity Insurance Agreement Managed Care Agreement Parity Insurance Benefits Lien Contract Receipt for Services Patient Fee Ledger Notice, Estimate, and Consent to Cost of Services Clinical Forms Treatment Plan Symptom Checklist Adult History Questionnaire Child History Questionnaire Medication Record Practice Management Professional Executor Instructions Click here to order your Professional Office Forms Kit. |
Office Forms Kit |