If you are accepted as a new patient, I can provide a link to our “NEW PATIENT PACKET” which contains all of these forms together and can be filled out online.
We have also provided the links below if you want to access these forms in printable format or just want to preview them in case you might have any questions prior to receiving access to the online versions.
If you do choose to use the printable versions here, you can scan/edit them and email the completed forms to drstone@drheatherstone.com or fax to (888) 478-1426 prior to the first session. We will then go over them together and I will answer any of your questions or concerns.
Required Forms
- Patient Information Form
Complete and sign hard copy, or open in Acrobat for prompts. - Notice of Privacy Practices
Review, sign, and return signature page if acceptable. - Consent for Psychotherapy Services
Review, sign, and return signature page if acceptable. - Consent to use email or text
Please review, sign, and return form. - Payment-Authorization
Please complete if you wish to pay with credit card. - Telemedicine Informed Consent
Please complete if you wish to use interactive audio or video conferencing as a venue for psychotherapy.
Optional Forms
- Authorization to Release Information
Optional: Please add third party (e.g. other medical provider), sign, and return form. - Authorization to Release — Collateral
Optional: Please add collateral — supportive person(s), sign, and return form. - Psychotherapy Collateral Agreement
Required with form above: Collateral participants should read, sign and return this form… - Medicare Opt-Out Form
Optional: Please sign and return form.