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*Please note, Shirley is an "Out of Network" provider. Read more here.
 
*Also, please note that Shirley does NOT treat Bipolar Disorder or prescribe stimulants or pain medication.
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© 2019 Shirley Furman Integrative Healing

Forms

Complete & Sign Prior To Your First Visit

New Client Intake Form / Patient Information

We will review this material briefly during the initial session.

Please fill out as much as possible and sign prior to your first visit.

Treatment Consent

Provides information about various treatments including but not limited to hypnotherapy, psychotherapy and medicine management.  

Please read carefully and sign prior to your first visit.

Consent for Release of Information

This form is very important if there are others that need to be contacted regarding your case.  Important individuals often include family members, previous clinicians, primary care doctors, etc.  Please remember that confidentiality is the foundation of effective mental health care.  You are always in charge of who receives information and is included in your treatment process.

Please read carefully and sign prior to your first visit.

Insurance Information

Shirley does not participate with insurance companies and will not bill your insurance directly.  However, she can provide you with a "Superbill" receipt for services rendered.  See more information here. Although she is not involved in the reimbursement process, it is still important to get medicine or other services covered if needed.

Please read carefully and sign prior to your first visit.

Credit Card Authorization

Since Shirley will hold appointment times for you, in return she requests that you fill out this form. Without discussing it with you directly, your credit card will only be charged in the following situation(s):

(a) cancellation less than 48 business hours in advance of your appointment

(b) no show for appointment

(c) additional services rendered agreed upon by you (e.g., phone sessions, report writing, etc.)

(d) lack of payment for appointments 

Please read carefully and sign prior to your first visit.

Receipt of Privacy Practices

Indicates that you received a copy of the HIPAA Notice & Privacy Practices. (see below)

Please read carefully and sign prior to your first visit.

For Your Information

HIPAA Notice & Privacy Practices

For your information serving as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act (HIPAA).

Please read carefully.