PENINSULA BEHAVIORAL HEALTH
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To save time and to get the most out of your first sessions, please download, print and fill out the forms below prior to your first session. Please don't hesitate to contact Dr. Adler at sarah@penbh.com with any questions.
Consent To Service 
This form describes the services I provide, limits of confidentiality, payment procedures and other matters regarding treatment. Please read the document carefully and sign where indicated, if you consent. The Consent to Service will become part of the clinical record. If you have questions regarding the form, please raise them at the beginning of the first session.
consent-to-services_adler.pdf
File Size: 249 kb
File Type: pdf
Download File

Client Background Form
This form helps me gather background information about you in order to facilitate our intitial meeting.
adler_intake_form.pdf
File Size: 219 kb
File Type: pdf
Download File

Release of Information Form
Completion of this form indicates that you consent for me to consult with family members and/or other providers who are specifically named on the form. This will only apply if you wish for me to be able to speak to someone else about our work together. If you have questions about whether you should complete a form, please discuss them with me. 
authorization_to_release_adler.pdf
File Size: 233 kb
File Type: pdf
Download File

HIPAA Notice of Privacy Practices. 
This form provides you with information regarding your rights related to Protected Health Information (PHI). The form is informational only.
The verification indicates that you have received the notice. 
notice_of_privacy_practices_adler.pdf
File Size: 229 kb
File Type: pdf
Download File

verification_of_privacy_notice_adler.pdf
File Size: 186 kb
File Type: pdf
Download File

Note: You will need a PDF viewer program such as Preview or Adobe Reader to view downloadable files. If you do not have one, you can download Adobe Reader here for free.
                                    © Peninsula Behavioral Health 2013     /  650-308-9215 /  info@penbh.com

This website is for informational purposes only. Direct consultation of a qualified provider should be sought for any specific questions or problems. Use of this website in no way constitutes professional service, advice, or establishing a professional relationship with Peninsula Behavioral Health.
  • Home
  • The Team
  • What we treat
  • Getting Started
  • Contact Us
  • StandTALL Clinic
  • Careers
  • Blog