Intake Forms

Billing insurance

If you would like for me to find out about your benefits and/or bill your insurance, the CMS/HCFA 1500 is required.  Please download the form and  fill it out.  You can then either scan it and email it to me along with a copy of your insurance card, and fax it to my office at (919) 933-0611, or bring it with you to your first visit.

NC Notice Form

This form is the North Carolina version of the Notice of Psychologists' Policies and Practices to Protect the Privacy of Your Health Information. This notice is not something you sign or consent to, rather it is information provided to you about what the law says about how psychological and medical information about you may be used and disclosed and how you can get access to this information. 

Psychotherapist-Patient Contract 

This is the contract for psychotherapy.  Please read it carefully as it spells out the contract that defines our doctor patient relationship. 

Release of Confidential Information

Quality medical care in integrated care.  If you are referred by a physician, it is very helpful for me to be able to communicate directly with him or her about your care, but in order to do so I will need to have your written consent.