Home
About Us
Links
FAQ's
Contact Us
Registration Forms
|
Registration Forms
|
If you have already scheduled an appointment with a therapist at Brassfield Center
for Psychotherapy and Personal Development, please print and complete the forms listed below.
Each therapist has provided the forms necessary for registration for their services.
A PDF reader is required to view and print the forms below.
Download Adobe Acrobat Reader
|
All therapists at Brassfield Center for Psychotherapy and Personal Development adhere
to Health Information Portability and Acknowledgment Act (HIPAA) guidelines regarding
information and privacy. You may review these guidelines by clicking the link
below.
Notice of Privacy Practices
Forms for clients of Marilyn Wolf, MEd, LPC, LCAS
Professional Disclosure Form
Client Confidential Information Form
Consent Acknowledgement Form
Forms for clients of Harriet Bullock, MS, LMFT
Consent Acknowledgement Form
Confidential Client Information Form
Forms for clients of Heidi Birkner, MA, LPC, LCAS
Professional Disclosure Form
Patient Information Form
Consent Acknowledgement Form
Forms for clients of Bridget Gwinnett, MS, LPC, NCC
Professional Disclosure Form
Registration Form
Consent Acknowledgement Form
Forms for clients of Lorraine T. Giardino, Ed.D., LPC, NCC, CCMHC
Authorization to Release Form
Confidential Client Information Form
Professional Disclosure Form
Insurance Information Form
Consent Acknowledgement Form
|
|
