Therapy Forms
Intake Forms:
In order to begin our work together you need to know who I am, what I can do and not do and my office procedures. I need to know some things about you and you need to give me permission to handle your information in various ways. You need to know the limits of confidentiality and what our agreement to work together looks like. There are three (3) forms you need to bring with you to our first session. They are:
New Client Questionnaire:
Practice Brochure:
HIPAA Privacy Notice and Consent Forms:
This form asks you basic information about who you are, how to contact you, who to contact in the event of an emergency, what your goals are in therapy, and any previous problems or issues you may have experienced. Please print and complete it and bring it with you to our first appointment. We will review it during our first session.
Download the New Client Questionnaire here.
The Practice Brochure helps you know who I am and what I am qualified to do and not do. It also presents my office procedures, gives me permission to bill your insurance company (if you are using insurance) and discusses the limits of confidentiality. Informing you about who I am and what to expect during our work together is part of a process called "Informed Consent". Informed consent helps you understand what seeing a psychologist is about. Please download the form and bring it to our first session. I will review it with you and answer any questions you may have.
Download the Practice Brochure here.
The Health Insurance Portability and Accountability Act (aka HIPAA) is a humongous law designed, among other things, to protect and ensure confidential handling of your protected health information (PHI). You need to read the HIPAA Privacy Notice, print the HIPAA Consent form (which is the last page of the form) and bring it to our first session. I will answer any questions you may have about privacy during the first session.
Download the HIPAA Privacy Notice and Consent form here.
My Schedule
My schedule is as follows:
Tuesdays: 11am - 8pm in Havertown
Wednesdays: 11am - 7pm in Media
Thursdays: 11am - 8pm in Havertown
If you have any questions or would like to schedule an appointment, please call: 1-888-933-3539.
I’d be happy to speak with you.
Mike Feeley