Andrew J. D'Amico Ph.D. LLC

Psychological Services for Children, Adolescents, Adults, and Families

Forms

Getting started with treatment involves understanding the therapeutic process. This information can be found in the forms below. Carefully read these forms before our first visit. When we meet I will explain each and answer your questions. The Client Information Brochure, The Notice of Privacy Practices, and the Permission for Telehealth Visits requires signed consent, executed only after you fully understand these forms and based on your degree of comfort. After discussing these forms with Andrew J. D’Amico simply print out the last page of the Client Information Brochure, The Notice of Privacy Practices, and the Permission for Telehealth Visits. Please sign the designated signature page, make a copy for your records, and mail directly to Andrew J. D’Amico, 1030 East Lancaster Avenue, Suite L-10, Rosemont PA 19010. (Also, If you are a Medicare Beneficiary you will also need to print out, sign, and make copy for your records the Medicare Opt out Patient Contract and mail to the above address). Thank you for your cooperation in this important process.

Client Bill of Rights
This is a document that states what your rights are while you are in treatment with me. You are entitled to discuss any of these items with me personally. I look forward to working with you!

Client Information Brochure — Informed Consent and Consent Form
Before starting treatment you have the right to know about what your treatment will entail. I am required to explain this to you. This is called informed consent and is contained in my client information brochure. This includes my qualifications, the benefits and risks of treatment, methods, your right to confidentiality and the limits to confidentiality, how long therapy might take, my work with children, adolescents and families, how I handle finances, how much my services cost, and other information about our relationship. It is necessary to sign the consent from in order to begin treatment. Parents must sign for minors.

Intake Evaluation
The Initial Intake Evaluation is crucial for diagnosis and treatment planning. Relevant clinical information includes the client face sheet and psychosocial/medical history for all age groups. By the end of the evaluation I will make a provisional diagnosis, collaborate with you on a treatment plan, and explain the behavioral protocol I will use in treating you.

Medicare Opt-out Contract

Notice of Privacy Practices (NPP) and Consent Form
HIPPA requires me to tell you how your protected health information (PHI) will be protected from unauthorized disclosures, and how it is used in my practice and disclosed to other covered entities (CES) for the purposes of treatment, payment, and health care operations (TPO). You must sign the consent form in order to begin treatment. Parents must sign for minors.

Permission for Telehealth Visits

Request/Authorization to Release Confidential Records and Information
You may request that I communicate with another provider about your care for the purposes of collaboration and treatment planning. The request/authorization to release confidential records and information must be signed in order to permit me to do this. Parents must sign for minors. The release covers authorization to obtain or to release records and it fully informs you about what is to be released and what will be done with the information.