Forms

 

Forms Available for Download

Please press the links below for each form you need and bring them on your next visit.


Download

Authorization to Disclose Health Information

Authorizing disclosure


I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed…


Download

Informed Consent for Counseling

Authorizing disclosure


The goals of counseling/psychotherapy are focused on supporting the individual and/or family through the processes associated with life transitions and relationships.


Download

HIPPA Notice of Privacy Practices

Authorizing disclosure


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.


Download

Acknowledgement of Receipt

Authorizing disclosure


By signing this form, you acknowledge receipt of the Notice of Privacy Practices that has been given to you. This Notice of Privacy Practices provides information about how your protected health information may be used and disclosed. You are encouraged to read it in full.


Download

Counseling Fee, Scheduling, And Cancellation Agreement

Understanding your payment process


I understand that payment is due at the time of each counseling or group session. Payment must be in the form of cash or check (please make checks payable to Jacqueline Small). I understand that I will need to reschedule a session if I cannot make payment at the scheduled appointment time.


Download

Client Information Form

Supporting the individual and/or family


Please, fill in this form and bring it with you, at the time of your appointment to see Jacqueline Small, LCSW 5575 Lake Park Way, Suite 100, #3 La Mesa, CA 91942


Stress Management

How to Reduce, Prevent, and Cope with Stress

How to Reduce Stress

10 Relaxation Techniques To Reduce Stress On-the-Spot

Benefits Of Exercise

13 Mental Health Benefits Of Exercise

Guided Meditations

Free Guided Meditations | UCLA Mindful Awareness Research Center

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