Michelle Allison LMFT
Licensed Marriage and Family Therapist
Individual and Family Psychotherapy for
Adults, Adolescents and Couples
Prior to your first appointment, you may download and print the following forms:
(If you do not already have Adobe Reader on your computer: Click on: Adobe Reader Download)
Client Registration: Adult (contains basic demographic and insurance information); please fill out this form and bring it to your appointment; bring your insurance card also. Applies to clients age 18 and older.
Click on: Adult registration2016.pdf
Client Registration: Child/Adolescent (contains demographic and insurance information); please fill out this form and bring it to your appointment; bring your insurance card also. Applies to clients under 18.
Click on: Child registration2016.pdf
Client Consent To Treatment: Print and bring this with you; you probably will not want to sign it until the initial interview is over and you have made decision about your treatment with me.
Click on: Client consent2016.pdf
Acknowledgment of Receipt of Notice of Privacy Practices: Please print this document, sign it, and bring it with you to your first appointment. This confirms you have been given the above Notice of Privacy Practices.
Click on: acknowledgment HIPAA.pdf
Notice of Privacy Practices: If you are interested the the details of the HIPPA Privacy Practices which describes your privacy rights regarding healthcare information, feel free to download and read this document. The Acknowledgment form is the one you will sign.
Click on: Privacy Notice2016
If you have questions or concerns about these forms, simply defer signing until they can be discussed at your first appointment.