Amanda Regan Mental Health Counseling, PLLC MS, LMHC, CASAC, NCC
Amanda Regan Mental Health Counseling, PLLC      MS, LMHC, CASAC, NCC

Forms

For your convenience, please print and complete these forms prior to your initial appointment and bring with you.

 

 

Intake
intake_form.doc
Microsoft Word document [40.0 KB]
Consent Form
informed_consent.doc
Microsoft Word document [41.5 KB]
Confidentiality Limits
limits_of_confidentiality.doc
Microsoft Word document [30.5 KB]
Release of Information
In order for information to be shared between your therapist and other parties a consent must be completed and signed.
authorization_for_release_of_personal_he[...]
Microsoft Word document [42.5 KB]
Additional Paperwork Policy and Fees
policy_for_additional_paperwork.doc
Microsoft Word document [28.5 KB]

Information to Print for Reference

Rights of the Client
client_rights.doc
Microsoft Word document [32.5 KB]
HIPAA Notice of Privacy
hipaa_notice_of_privacy_practices.doc
Microsoft Word document [31.5 KB]
Emergency Contact Information
key_contact_sheet.doc
Microsoft Word document [31.0 KB]

Contact Me Today!

Amanda Regan MS, LMHC, CASAC, NCC
722 Weiland Rd Suite 200
Rochester, New York 14626

Phone:  (585) 420-7280

Email: ar@AmandaReganMentalHealthCounseling.com

Print Print | Sitemap
© Amanda Regan PLLC