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Client Forms
September 7th, 2009
Before attending the first session, please fill out the “Intake Form” and the “Informed Consent.”
If you would like for me to speak with collateral resources, such as your doctor, psychiatrist, teacher, or family please fill out the “Exchange of Information Release” form.
If you will be using your insurance, or if I am in direct contact with your Insurance Provider, you also need to fill out the Protected Health Information HIPAA Authorization Form (PHI) so I will be able to speak with your insurance company.
These forms may not be used for any purpose other than for clients of Michael Uram, MA, LMFT without prior authorization.
Authorization to Exchange Information
HIPAA Authorization for Insurance
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