Lori Gaylor MS, LPC
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  • TELEHEALTH
  • New Patients
    • Forms
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  • COVID-19 Notice
  • Home
  • About
  • Location
  • Contact
  • TELEHEALTH
  • New Patients
    • Forms
    • Rates
  • Pay Online
  • Resources
  • COVID-19 Notice

Below are the forms needed for your first appointment:

If you are being seen through our TELEHEALTH system you will receive an email containing links to our e-forms to submit online.

If you are coming into our OFFICE we ask that you please print and fill out the applicable forms and bring them to your first visit. 

The following five forms are needed from every patient: 
Patient information
Consent to treatment
Hipaa Privacy policy
Email/Text Consent
Confidentiality in therapy
The Teletherapy Informed Consent and Credit Card Authorization Form is only needed by those scheduling teletherapy sessions.
Telehealth Informed Consent
Credit Card Authorization Form
The Insurance Agreement form is only needed from patients that will be using their insurance for payment.
insurance agreement
The Financial Information form is only needed from patients that will NOT be utilizing insurance:
financial information

Required for Children/Teens:                                              Required for Adults:
child characteristics checklist
adult concerns checklist
amen child-teen checklist
amen adult symptom checklist
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