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.
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 |
Client Background Form
This form helps me gather background information about you in order to facilitate our intitial meeting.
This form helps me gather background information about you in order to facilitate our intitial meeting.
| adler_intake_form.pdf |
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.
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 |
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.
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 |
| verification_of_privacy_notice_adler.pdf |
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.
