Please click on the links below, fill each form out completely and bring them on your next visit.
Authorization to Disclose Health InformationI 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…
Please press the links below for each form you need and bring them on your next visit.
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.
Please press the links below for each form you need and bring them on your next visit.
HIPPA Notice of Privacy PracticesAuthorizing 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.
Please press the links below for each form you need and bring them on your next visit.
Acknowledgement of ReceiptAuthorizing 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
Please press the links below for each form you need and bring them on your next visit.
Counseling Fee, Scheduling, And Cancellation AgreementAuthorizing disclosure
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.
Please press the links below for each form you need and bring them on your next visit.
Client Information FormAuthorizing disclosure
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, LCSW21926, 5575 Lake Park Way, Suite 100, #3 La Mesa, CA 91942
Please press the links below for each form you need and bring them on your next visit.
