Client Forms
Adult new client forms
These are the new client forms for clients age 18 and older. Clients who have not yet turned 18 should use the Child and Adolescent New Client Forms instead of this link.
New Client Forms - Adults MASTER.pdf
Adobe Acrobat document [198.6 KB]
These are the new client forms for clients age 18 and older. Clients who have not yet turned 18 should use the Child and Adolescent New Client Forms instead of this link.
New Client Forms - Adults MASTER.pdf
Adobe Acrobat document [198.6 KB]
Child and Adolescent New Client Forms
These are the new client forms when the identified client is age 17 and under. Clients who have turned 18 should use the Adult New Client Forms instead of this link. Please note that clients who are age 12 and over are required to sign all documents where it says "Client Signature."
Child and Adolescent New Client Forms MA[...]
Adobe Acrobat document [229.9 KB]
These are the new client forms when the identified client is age 17 and under. Clients who have turned 18 should use the Adult New Client Forms instead of this link. Please note that clients who are age 12 and over are required to sign all documents where it says "Client Signature."
Child and Adolescent New Client Forms MA[...]
Adobe Acrobat document [229.9 KB]
Authorization to Release Information Form
If you have information that you would like for another clinician, teacher, school, pediatrician, psychiatrist, hospital, or other provider or family member to be able to share with Insight Therapeutics, please complete this form. Please note that failure to complete it properly renders the form INVALID, so please check with your therapist regarding how to complete the form if you have questions.
ROI MASTER.pdf
Adobe Acrobat document [437.9 KB]
If you have information that you would like for another clinician, teacher, school, pediatrician, psychiatrist, hospital, or other provider or family member to be able to share with Insight Therapeutics, please complete this form. Please note that failure to complete it properly renders the form INVALID, so please check with your therapist regarding how to complete the form if you have questions.
ROI MASTER.pdf
Adobe Acrobat document [437.9 KB]
HIPAA Rights
This document contains your rights according to the Health Insurance Portability and Accountability Act, commonly known as HIPAA. Clients are responsible for being aware of their rights through this form, but do not need to print or bring this form with them to appointments.
HIPAA 09-01-2016 MASTER.pdf
Adobe Acrobat document [744.5 KB]
This document contains your rights according to the Health Insurance Portability and Accountability Act, commonly known as HIPAA. Clients are responsible for being aware of their rights through this form, but do not need to print or bring this form with them to appointments.
HIPAA 09-01-2016 MASTER.pdf
Adobe Acrobat document [744.5 KB]
Certification of Authority - for parents or legal guardians of any client who is not their own guardian
Parents who are bringing their child to treatment (under age 18) and are not currently married to the child's second parent need to complete this form. If you have questions about this, please discuss them with your clinician. In most circumstances, therapy with someone under the age of 18 requires consent of BOTH parents/guardians UNLESS there are legal documents (such as an Order of Protection, Joint Parenting Agreement, Divorce Decree, etc.) stating otherwise. In addition, parents who are bringing their adopted children for services are also required to complete this form.
Certification of Authority MASTER.pdf
Adobe Acrobat document [80.2 KB]
Parents who are bringing their child to treatment (under age 18) and are not currently married to the child's second parent need to complete this form. If you have questions about this, please discuss them with your clinician. In most circumstances, therapy with someone under the age of 18 requires consent of BOTH parents/guardians UNLESS there are legal documents (such as an Order of Protection, Joint Parenting Agreement, Divorce Decree, etc.) stating otherwise. In addition, parents who are bringing their adopted children for services are also required to complete this form.
Certification of Authority MASTER.pdf
Adobe Acrobat document [80.2 KB]
Payment Information Form
This form allows clients to have a credit card on file for billing purposes. Please note that we will always ask for the physical card at the time of session, as this is the most secure method of payment. This form must also be co-signed by the actual cardholder, whether the client is a child, teen, or adult.
Payment Information Form.pdf
Adobe Acrobat document [490.8 KB]
This form allows clients to have a credit card on file for billing purposes. Please note that we will always ask for the physical card at the time of session, as this is the most secure method of payment. This form must also be co-signed by the actual cardholder, whether the client is a child, teen, or adult.
Payment Information Form.pdf
Adobe Acrobat document [490.8 KB]
Print 