Our Forms

Forms Before Your First Session

Client Forms:

Your clinician will provide electronic versions of our forms. This should allow you to complete and submit all paperwork electronically. Sending ahead of time is preferred and allows your clinician to review background information prior to the appointment.

If our electronic forms are not accessible to you, please contact your clinician directly for alternative methods of completion. Please contact info@birchpsychology.com with any issues relating to our electronic forms.

The forms you will be asked to complete or sign will be:

  1. A Background Information Form

  2. A Consent Agreement

  3. A Mandatory Disclosure

  4. A Receipt of Privacy Information Form

  5. A Payment Information Request Form

  6. A Good Faith Estimate Agreement (sent after initial sessions phase)

The forms you may be asked to complete or sign:

  1. Authorization to Release Information Form

  2. Telepsychology Agreement Form

Other Forms (Downloadable):

Individuals completing sliding scale requests should complete this form. Sliding scale requests should be discussed at the time of the initial phone consultation. Sliding Scale Request Form.

Professionals/providers seeking a convenient and more efficient method of referring an individual, and establishing collaborative communication for the purpose of continuity (with permission), can complete Birch's Referral Form.

Pediatric providers are welcome to utilize the following resources: Decision-Making Form (to aid with steps to take relating to mental health concerns following a brief assessment using the PHQ-9: http://www.cqaimh.org/pdf/tool_phq9.pdf) and a Coping Tools Resource. 

Other Information:

Good Faith Estimate/ No Surprises Act

Here is more information about the No Surprises Act, beginning 1/1/2022. This pertains to individuals obtaining medical services without the use of insurance and their rights. A good faith estimate will be provided to you at your request, as well as at the determination of the therapy, assessment or consultation plan.

Notice of Good Faith Estimate