The forms below are provided in Adobe Acrobat format for ease of printing. Most newer computers come with the software already installed but if you receive an error message, please download the free Adobe Acrobat Reader.

For Scheduling a First Time Appointment:

If you are a PARENT of a child and will be scheduling an appointment with us, please download and complete the following forms and bring them with you on your first visit:

1. Notice of Privacy Practices
2. Business Policy
3. Patient Information

If you are a COLLEGE STUDENT OR ADULT and will be scheduling an appointment with us, please download and complete the following forms and bring them with you on your first visit:

1. Notice of Privacy Practices
2. Business Policy
3. Adult Information Sheet (if you are a college student, page 2 must also be completed)

RELEASE OF INFORMATION

For your privacy, we must have an authorization form completed and returned for uses and disclosure of your protected healthcare information.You may download, complete, and return this page to us so that we can release or exchange information with other individuals and offices. Please download the Authorization Form for Uses and Disclosures and upon its completion, you may either fax this form to our office (919-790-1521) or return it via US Mail to the Raleigh address listed below.

Release of psychotherapy notes requires a greater degree of privacy and a different level of consent. You may call the office for instructions on how to do this but we will require additional verification of your personal signature, witness, or driver's license prior to any psychotherapy notes being released.

WHAT TO READ AND FILL OUT

We know that reading and completing these forms is long and complex. However, the Federal Government (HIPAA) requires us to inform you of your privacy rights as well as our need to inform you about our practice and our business policies.

Please take the time to read the information carefully, complete the forms, and bring them with you to your first appointment. You will have to bring these with you or fill them out at the first appointment before you are seen.

If there is anything on the forms that you do not understand before filling them out, please feel free to contact our office at 919-876-5658.

CREDIT CARD AUTHORIZATION

You may prefer to pay for services received at this office by credit card.  Please download the credit card authorization form and fax to our office (919-790-1521) or return via US Mail.

BOOKLET ORDER FORM

Please download the booklet order form if you would like to purchase any of the following booklets:

• Attention-Deficit/Hyperactivity Disorder (ADHD)
  How to recognize ADHD, common questions asked about the course of ADHD, how it is diagnosed, the role of medication and how children can be helped at home and at school are succinctly addressed in this compact booklet.
  
• Eating Disorders
  This 30-page booklet covers the definition and characteristics of anorexia and bulimia, how one can tell if food or weight has become a problem, medical complications, causes, what treatment must cover, and guidelines for helping a friend or family member with eating disorders in a practical manner.
  
• Divorce – How Not to Make a Bad Situation Worse
  How to tell children about parents’ impending decisions, how to make transitions between parents go smoothly, and factors that influence children’s psychological adjustment after the separation are addressed.
  
• Homework – Getting It Done
  Finally!  A booklet designed for parents who are experiencing problems in getting children to work independently.
  
• Learning Disabilities
  This 30-page booklet covers the definition and characteristics of LD, causes, tips on talking to children about LD, and tips for parents and teachers in working with LD children.