 |
 |
 |
 |
 |
 |
 |
| Thank you very much for filling these forms out ahead of time. |
PortlandCounseling.net Portland Counseling & Psychotherapy |
Psychotherapy Counseling Coaching Marital Therapy Couples Counseling Personal Development Goal Setting Decision Making LGBT Friendly |
| Christian Wolff, Psy.A., Portland Psychologist Associate/ Counselor 820 NW 21st Avenue, Suite B. Portland.Oregon. 97209. 503.381.2032. christian@christianwolff.com |
Instructions for Forms
(the Paperwork):
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
their first session. To view, click on the underlined words. Brief instructions for each form are
in red type. 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.
The Forms:
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.
Treatment Contract * (Informed Consent to Treatment)
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 * Required Only If You Are Using Insurance
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.
Authorization to Use or Disclose Health Information
This form will only if you want to give me written permission to speak with someone else
about your therapy. Unless you fill out this form out, I cannot speak with anyone but you
about your therapy. One of these can be filled out at anytime during therapy but if there is
no one you wish for me to speak with now, you do not need to fill out this form at all for
now.
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.
(the Paperwork):
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
their first session. To view, click on the underlined words. Brief instructions for each form are
in red type. 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.
The Forms:
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.
Treatment Contract * (Informed Consent to Treatment)
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 * Required Only If You Are Using Insurance
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.
Authorization to Use or Disclose Health Information
This form will only if you want to give me written permission to speak with someone else
about your therapy. Unless you fill out this form out, I cannot speak with anyone but you
about your therapy. One of these can be filled out at anytime during therapy but if there is
no one you wish for me to speak with now, you do not need to fill out this form at all for
now.
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.
alternative
websites:
ChristianWolff.com
The American
Mental Health
Alliance
Psychology Today
Mental Help
The Oregon Board of
Psychologist
Examiners
The Willamette
Week
Merchant Circle
Linked In
Life Quality
Improvement Center
All About Counseling
iPsychotherapist
KBOO Radio
Member Benefits
When You Know Its
Time
The Clinical Registry
websites:
ChristianWolff.com
The American
Mental Health
Alliance
Psychology Today
Mental Help
The Oregon Board of
Psychologist
Examiners
The Willamette
Week
Merchant Circle
Linked In
Life Quality
Improvement Center
All About Counseling
iPsychotherapist
KBOO Radio
Member Benefits
When You Know Its
Time
The Clinical Registry