Before Our First Appointment

So as to minimize the time we must spend addressing administrative matters, please download the five federally mandated forms listed below, review them, and email the relevant pages to me before our first session. 

 

1. Client Info Form

Please complete this form and bring it with you to the appointment. With the version on the left (Word) you may type directly into the form and email it to me. If you are unable to open a docx file, you can print out the form, complete and take photos of each page and email it to me before our appointment. Clients for couples therapy: Please each complete the form separately (Word or pdf) and email it to me before our first session.

Client Info Form.docx Client Info Form.docx
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Client Info Form.pdf Client Info Form.pdf
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2. HIPAA Notice

This is the Health Insurance Portability and Accountability Act notice. All health providers must give this to their patients. If you are unfamiliar with the HIPAA Notice, please read it. Please sign the last page and either email the whole document to me, or and take a photo of the signed page and email that to me before our appointment.   Clients for couples therapy: Please both sign the last page of the HIPAA Notice for COUPLES (form on the right) and email it to me before our first session.

HIPAA_Notice-2022.pdf HIPAA_Notice-2022.pdf
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HIPAA_Notice-Couple.pdf HIPAA_Notice-Couple.pdf
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3. Psychotherapy Agreement

This form explains my office policies and relevant laws about confidentiality in more detail. Please read this agreement, sign the last page and email the file or just that page before your first appointment. If you are unable to open a docx file, you can print out the last page of the pdf version on the right and take a photo of the signed page. Clients for couples therapy: Please together sign the last page of the Psychotherapy Agreement for COUPLES (lower form--either in Word or pdf) and email it to me before our first session.

Psychotherapy Agreement 2022.docx Psychotherapy Agreement 2022.docx
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Psychotherapy Agreement 2022.pdf Psychotherapy Agreement 2022.pdf
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Couple Agreement 2022.docx Couple Agreement 2022.docx
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Couple Agreement 2022.pdf Couple Agreement 2022.pdf
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4. Telehealth Form 

This form (available in Word and pdf) allows us to have appointments via encrypted video or by telephone. Please complete, sign, and email back to me before our first session. Clients for couples therapy: Please each sign your own copy either in Word or pdf--and  email it to me before our first session.

Telehealth.docx Telehealth.docx
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Telehealth.pdf Telehealth.pdf
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5. No Surprises Act Notice

This form  explains the No Surprises Act which went into effect January 1, 2022 and which offers protections from surprising medical bills. Please read this.

Feb 2022 GFE Web Notice.pdf Feb 2022 GFE Web Notice.pdf
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Robin S. Rosenberg, Ph.D., ABPP
Clinical Psychologist

650-440-5534

 
Cal. Lic. #24085                       
Mass. Lic. #4604
NY Lic. #021395