Forms to fill out prior to your first session:
Instructions:
The following is a list of various documents and forms which you may wish to view or print. The forms with an asterisk (*) are the forms
most people will need to review or fill out prior to our first meeting. To view, click on the yellow high-lighted words. Brief instructions are
included in yellow. To print, you may print these documents in the same way as you would any other document.
Note: These forms are PDF and require Adobe Acrobat Reader. Download it here for free.
If you are unable to print these forms out, please let me know and I will have hard copies printed which you may complete in the waiting
room prior to your first session.
Privacy Policy *
This is a document describing the privacy of information I follow in the delivery of my services. It has to do with confidentiality. Please
read this. There is nothing to fill out, but it is important you read it prior to signing the treatment contract.
Informed Consent (Treatment Contract) *
All persons who receive treatment services from me must review and sign a treatment contract. You may wish to review this prior to our
first meeting but we will go over it together before you sign it. This form is sometimes called an "informed consent" form and includes
information on rights and responsibilities. Although it reiterates some of the information in the Privacy Policy, this is a signed document
which states that you have been informed of certain standard limits to privacy and are still consenting to treatment. The limits to privacy
are actually very few but by being informed, you can make better decisions about what to, and what not to tell me. The only restrictions to
privacy are those required by law.
Adult Questionnaire *
This is a standard questionnaire I ask most adults to fill out prior to our first session. For those with concerns about their mental health,
this will help us to get a good start in the right direction. For those without mental health concerns per se, this will still be helpful and it will
help us rule out any mental health concerns which may not be initially apparent. Please fill this out prior to our first session and bring it with
you.
Front Page *
This is a simple "front page" which will give me easy access to your name, address, contact numbers, emergency numbers, and so on.
Please fill this out and bring it with you to your first session.
Fee Agreement *
This a form that establishes our agreement about payment. Whether I bill your insurance, you bill your own insurance, or you pay me
directly out of pocket, it is important that we agree about fees from the beginning. This will help us avoid misunderstandings (or unpleasant
surprises). This form will need to be signed before we begin, but many people choose to wait until they arrive and have had an opportunity
to ask questions.
Cancellation Policy *
This is a form that establishes our agreement about cancellations. Please sign this page and bring it with you at the time of your first
session.
Insurance Information Parts I & II
These are the forms you will need to fill out if you wish for me to bill your insurance company for my services. If you are planning to use
insurance to pay for services, please fill this out and bring it with you to your first session. * Required for insurance use.
Authorization to Use or Disclose Health Information
This form is sometimes called a release of information (ROI). Under most circumstances, I am not allowed to share information with others
without your permission. This is the form you will need to fill out and sign in order for me to communicate with other parties. If you already
know that you will wish for me to communicate with certain other people or organizations, you may wish to print this page and have it ready
for when you come in. Examples of others you may wish for me to communicate with or receive records from include medical providers,
clergy persons, community organizations, other therapists, and friends or family.
Thank you very much for filling these forms out in advance.
The following is a list of various documents and forms which you may wish to view or print. The forms with an asterisk (*) are the forms
most people will need to review or fill out prior to our first meeting. To view, click on the yellow high-lighted words. Brief instructions are
included in yellow. To print, you may print these documents in the same way as you would any other document.
Note: These forms are PDF and require Adobe Acrobat Reader. Download it here for free.
If you are unable to print these forms out, please let me know and I will have hard copies printed which you may complete in the waiting
room prior to your first session.
Privacy Policy *
This is a document describing the privacy of information I follow in the delivery of my services. It has to do with confidentiality. Please
read this. There is nothing to fill out, but it is important you read it prior to signing the treatment contract.
Informed Consent (Treatment Contract) *
All persons who receive treatment services from me must review and sign a treatment contract. You may wish to review this prior to our
first meeting but we will go over it together before you sign it. This form is sometimes called an "informed consent" form and includes
information on rights and responsibilities. Although it reiterates some of the information in the Privacy Policy, this is a signed document
which states that you have been informed of certain standard limits to privacy and are still consenting to treatment. The limits to privacy
are actually very few but by being informed, you can make better decisions about what to, and what not to tell me. The only restrictions to
privacy are those required by law.
Adult Questionnaire *
This is a standard questionnaire I ask most adults to fill out prior to our first session. For those with concerns about their mental health,
this will help us to get a good start in the right direction. For those without mental health concerns per se, this will still be helpful and it will
help us rule out any mental health concerns which may not be initially apparent. Please fill this out prior to our first session and bring it with
you.
Front Page *
This is a simple "front page" which will give me easy access to your name, address, contact numbers, emergency numbers, and so on.
Please fill this out and bring it with you to your first session.
Fee Agreement *
This a form that establishes our agreement about payment. Whether I bill your insurance, you bill your own insurance, or you pay me
directly out of pocket, it is important that we agree about fees from the beginning. This will help us avoid misunderstandings (or unpleasant
surprises). This form will need to be signed before we begin, but many people choose to wait until they arrive and have had an opportunity
to ask questions.
Cancellation Policy *
This is a form that establishes our agreement about cancellations. Please sign this page and bring it with you at the time of your first
session.
Insurance Information Parts I & II
These are the forms you will need to fill out if you wish for me to bill your insurance company for my services. If you are planning to use
insurance to pay for services, please fill this out and bring it with you to your first session. * Required for insurance use.
Authorization to Use or Disclose Health Information
This form is sometimes called a release of information (ROI). Under most circumstances, I am not allowed to share information with others
without your permission. This is the form you will need to fill out and sign in order for me to communicate with other parties. If you already
know that you will wish for me to communicate with certain other people or organizations, you may wish to print this page and have it ready
for when you come in. Examples of others you may wish for me to communicate with or receive records from include medical providers,
clergy persons, community organizations, other therapists, and friends or family.
Thank you very much for filling these forms out in advance.
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| Christian Wolff, Psy.A., Licensed Psychologist Associate • Psychotherapist & Counselor 820 NW 21st Avenue, Suite B. Portland.Oregon. 97209. 503.381.2032. christian@christianwolff.com |