Andrew J. D'Amico Ph.D. LLC

Psychological Services for Children, Adolescents, Adults, and Families

Forms

The following forms are necessary to start treatment. In order to save time in our first meeting I ask that you review, print, and complete the informed consent and notice of privacy forms by signing the attached consent forms. In addition, if you are a Medicare Beneficiary, you will need to sign the form stating that you are aware that I have opted out of Medicare. Also if you wish for me to speak to another provider, please review and sign the release of information. Please bring these to our initial evaluation. I will answer any questions at the time. Please do not sign anything unless you are comfortable. Below you will find a brief explanation of each form and why it is necessary.

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.

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.

The 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.

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.

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!