Patient Forms

Below you will find a variety of forms for new patients or individuals considering our services.

Notice of Privacy Practices
This document describes how we handle your private information.

Patient Services Agreement
This document outlines our policies for providing services and a general description of our approach to therapy.

Good Faith Estimate/Fees & Financial Policies
This document provides details about the cost of our services as well as our various financial policies.

Telepsychology Consent Form
This form describes our policies and procedures for providing services via telecommunications.

Charitable Grant Program
This form describes our Charitable Grant Program for individuals who need our services but otherwise cannot afford to pay for them.

Charitable Grant Application (Doctoral-Level Providers: Drs. Sodergren, Dowdell & Murphy)
This form is to be completed by patients who wish to receive a Charitable Grant to help offset the cost of services with one of our doctoral-level providers. It contains guidelines for grant amounts. Please note that the dollar amounts included are guidelines only and are subject to change. When applying for a grant, we ask that you prayerfully consider what you could afford to pay per session, keeping in mind the need for a just distribution of our resources.

Charitable Grant Application (Masters-level Providers: Wallace & Hernon)

This form is to be completed by patients who wish to receive a Charitable Grant to help offset the cost of services with one of our masters-level providers. It contains guidelines for grant amounts. Please note that the dollar amounts included are guidelines only and are subject to change. When applying for a grant, we ask that you prayerfully consider what you could afford to pay per session, keeping in mind the need for a just distribution of our resources.