• Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  •  -
  •  - -
    Pick a Date
  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.

  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.

  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Acknowledgement of Receipt of Professional Disclosure Statement and Informed Consent

     SIGNATURE BELOW INDICATES THAT YOU HAVE REVIEWED THE AGREEMENT TITLED “PROFESSIONAL DISCLOSURE STATEMENT” AND YOU AGREE TO ITS TERMS. THIS DOCUMENT INFORMS YOU ABOUT MY BACKGROUND, DISCLOSES MY PHILOSOPHY OF THERAPY, AND INFORMS YOU OF POLICIES, PROCEDURES, LEGAL AND ETHICAL CONSIDERATIONS. THE LATEST PROFESSIONAL DISCLOSURE STATEMENT IS AVAILABLE ON MY WEBSITE UNDER “DISCLOSURE STATEMENT”. 

     

     

  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Acknowledgement of Receipt of Privacy Notice

    I have carefully reviewed and understand the Notice of Privacy Policy. The latest version of this policy is available on my website under “Privacy Statement”. The Notice of Privacy Policy describes how my medical information may be used and disclosed and how I can get access to this information. At any time I may request further explanation regarding the use and disclosure of my protected health information.

  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Please be sure to provide your insurance card at our first session. If you do not have your insurance card, you will need to pay in full for the appointment. A refund will be issued if the insurance is successfully billed at a later date.

    I authorize the release of all medical records to my insurance company. I further authorize insurance payments to be made directly to Anne M. Coleman, LCSW. I understand co-payments, deductibles, self-pay charges are due at time of service regardless of whether the guarantor is present. Charges for services provided between appointments are due at the next appointment or when billed.

     

  • Client Intake Form

    Please Complete This Intake Prior to Your First Appointment with Me.
  • Financial Policy

    For managing account information and for convenience I am able to provide a monthly statement of charges. If you choose to use your insurance, I am glad to file the proper paperwork. You will be responsible for the remaining balance not covered by insurance – such as copays, co-insurance and sometimes deductibles. All patients must provide a valid credit card to guarantee payment for services. The guarantor may also elect to authorize that the weekly charges for my services be automatically posted to a designated credit card at the end of each week.

    Credit Card information is required

     

     

  • Should be Empty: