Abraham Aviles-Scott
Licensed Marriage & Family Therapist
All new clients should complete the following four forms and return them before your first session. Each member of couples or family sessions should complete their own set of forms.
Note: These fillable forms work best in Acrobat. To download Adobe Acrobat Reader for free, click here.
Note: These fillable forms work best in Acrobat. To download Adobe Acrobat Reader for free, click here.
1. Intake Questionnaire (complete, sign, and return)
|
| ||||
2. Informed Consent (complete, sign, and return)
|
| ||||
3. Acknowledgement of Receipt of Privacy Practices (complete, sign, and return)
|
| ||||
4. Notice of Privacy Practices (KEEP for your records)
|
| ||||
Telehealth clients (audio and/or video through a personal computer or mobile device) should complete this Informed Consent for Telehealth Services. I provide telehealth with Zoom video conferencing. Visit https://zoom.us/ for instructions or more information. Zoom is available as a desktop or mobile app (see this page for links).
5. Informed Consent for Telehealth (complete, sign, and return)
|
| ||||
If you want me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please complete an Authorization for Use or Disclosure of Protected Health Information.
6. Authorization for Disclosure
|
| ||||
If you want to put a credit card on file for future charges, please complete and return this form. I will email a Square receipt at the time of each charge.
7. Card on File Authorization
|
| ||||
