Intake Forms

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Clinical Services (Therapy, Evaluations/Testing, Neurofeedback)
Forensic Services (Evaluations for Use in Court; Forensic Consults)
Divorce Services (Co-Parenting; Parenting Plan Assistance; Child Specialist)
Business Services

Initial Appointment Forms for Clinical Services / Therapy & Evaluation

You may download these forms, which are provided as PDFs, should you wish to familiarize yourself with them before your first appointment. Forms include our mental health services agreement, description of educational and psychological testing, the NC Notice related to confidentiality, and our consent to release information form. It will save time in your first appointment if you print and fill in the appropriate forms, and bring them with you, rather than filling them out during your appointment. If you are coming in for THERAPY you only need to fill out form #1; if you are coming in for an EVALUATION you need to fill in forms #1 and #3. #2 is for you to view and we do not need a copy. #4 is for use if you would like us to speak with someone about your case; if having an evaluation your evaluator may want you to provide some collateral contacts. For clients coming in for Neurofeedback only, you only need to do form #5.

1. LEPAGE ASSOCIATES MENTAL HEALTH SERVICE AND FEE AGREEMENT
Information Concerning The Practice, Financial Arrangements, Confidentiality
and Patients’ Rights

2. NORTH CAROLINA NOTICE FORM
Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information

3. LEPAGE ASSOCIATES EVALUATION SERVICES AND FEE AGREEMENT
Information Describing What Each Evaluation Assesses For and Its Usefulness Plus What Each Entails, and Financial Arrangements (If your evaluation will be used in court, use the Forensic Evaluation form under INITIAL FORMS FOR FORENSIC SERVICES below.)

4. CONSENT TO RELEASE AND EXCHANGE INFORMATION FOR CLINICAL SERVICES
By signing this form you allow us to exchange information with other professionals. For example, for minors it may be helpful for us to be able to speak with school personnel (teachers, school counselors). If the client has seen a previous therapist or had previous testing, this might be useful information for us to have. Any client who is presently using psychiatric medication should fill this out so that we may speak with the prescribing psychiatrist or practitioner. We must have a signed release form to be able to speak with anyone about your treatment.

5. NEUROFEEDBACK SERVICE AND FEE AGREEMENT

Initial Appointment Forms for Forensic Services

You may download the following forms, which are provided as PDFs, should you wish to familiarize yourself with them before your first appointment. It will save time in your first appointment if you print and fill in these forms, and bring them with you, rather than filling them out during your appointment.

In particular, the custody evaluation form is very long; if you cannot fill this out before the day of your appointment please plan to come at least 30-60 minutes in advance of your appointment time to complete the forms at the office. Your first appointment cannot begin until the forms are filled out.

Clients seeking a Custody Evaluation need ONLY the TWO forms below that relate to custody (forms 3 & 4).

1. LEPAGE ASSOCIATES FORENSIC EVALUATION SERVICES AND FEE AGREEMENT
Information Describing What Each Evaluation Assesses For and Its Usefulness Plus What Each Entails, and Financial Arrangements

2. LEPAGE ASSOCIATES FORENSIC CONSULTANT SERVICE AND FEE AGREEMENT
Information Concerning the Practice, Financial Arrangements, and Confidentiality

3. CUSTODY EVALUATION SERVICE AND FEE AGREEMENT
Information Concerning the Practice, Financial Arrangements, and Confidentiality

4. CONSENT TO RELEASE AND EXCHANGE INFORMATION FOR CUSTODY EVALUATION

Initial Appointment Forms for Divorce Services

You may download the following forms, which are provided as PDFs, should you wish to familiarize yourself with them before your first appointment. It will save time in your first appointment if you print and fill in these forms, and bring them with you, rather than filling them out during your appointment.

Clients seeking Divorce Consult Services to include: an informational process consult to determine what type of divorce process might work best for you; communication skill building to prep for meetings; preparation and assistance through the process; child specialist consultation; parenting plan consults/mediation; and/or coaching for cooperative co-parenting services use the first two forms below.

1. LEPAGE ASSOCIATES DIVORCE CONSULTANT SERVICE AND FEE AGREEMENT
Information Concerning the Practice, Financial Arrangements, and Confidentiality

2. NORTH CAROLINA NOTICE FORM
Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information

Initial Appointment Forms for Business Services

You may download this form, which is provided as a PDF, should you wish to familiarize yourself with it before your first appointment. It will save time in your first appointment if you print and fill in this form, and bring it with you, rather than filling it out during your appointment. The form included is out services agreement for employers within the workplace, which includes executive coaching, conflict mediation and resolution, consulting for organizational planning, personal and professional growth seminars, and informational talks.

SERVICES AND FEE AGREEMENT FOR BUSINESS SERVICES