Please download the first six forms, fill them out and bring them to your first appointment, or with Telemedicine scan as PDFs and email them to me. You can also fax, put in the US Mail to my Santa Clarita office or drop off to the lock box at the front door of my Santa Clarita office. Either way, I need them them at least 24 hours before  the 1st appointment. E-Mail is [email protected], fax is 661 254-8574 and the phone numbers are 661 259-3704 (SCV) and 323 935-1034 (WLA).

• Patient Information
• HIPPA Notice of Privacy Practices  To see a full copy of the HIPPA Privacy Practices Law, click here.
  
• Informed Consent and Agreement for Treatment
• Credit Card Approval Form
• Telemedicine Informed Consent Form
• Assessment Tools

Other forms which may be needed.

• HIPPA Release Form – So that I may talk to your attorney, physician, teacher school counselor or other third party.
• Consent to Treat Minors – In a divorce situation, use this form to get the other parent’s approval to treat the child.
• Collaterals VS Patients – This form must be signed by anyone in the session who is not the patient.
• EMDR Consent Form – If you will be doing EMDR Therapy, this informative form gives written permission for treatment.
• Patient Election to Self Pay for Services – This form must be signed if you decide to not use your insurance and pay for services yourself. 
• Neurofeedback and Biofeedback Intake Questionnaire  – Patients coming to Biofeedback or Neurofeedback for any issue, please fill this form out so I may learn your history and symptom.
• qEEG Guided Neurofeedback Informed Consent – Agreement for Treatment – If coming in for a Brain Map (qEEG) this form gives permission for treatment.