Abraham Aviles-Scott
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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.
1. Intake Questionnaire (complete, sign, and return) [Fillable form as of 10/7/2022.]
intake_questionnaire_100422.pdf
File Size: 407 kb
File Type: pdf
Download File

cuestionario_de_admision_100422.pdf
File Size: 1327 kb
File Type: pdf
Download File

2. Informed Consent (complete, sign, and return) [Fillable form as of 10/4/2022.]
informed_consent_100422.pdf
File Size: 210 kb
File Type: pdf
Download File

consentimiento_informado_100422.pdf
File Size: 241 kb
File Type: pdf
Download File

3. Acknowledgement of Receipt of Privacy Practices (complete, sign, and return)​ [Fillable form as of 10/4/2022.]
acknowledge_privacy_practices_100422.pdf
File Size: 151 kb
File Type: pdf
Download File

consentimiento_informado_100422.pdf
File Size: 246 kb
File Type: pdf
Download File

4. Notice of Privacy Practices (KEEP for your records)
notice_of_privacy_practices_080119.pdf
File Size: 522 kb
File Type: pdf
Download File

notificacion_de_practicas_de_privacidad_083020.pdf
File Size: 463 kb
File Type: pdf
Download File


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)​ [Fillable form as of 10/4/2022.]
informed_consent_telehealth_100422.pdf
File Size: 133 kb
File Type: pdf
Download File

consentimiento_informado_telesalud_100422.pdf
File Size: 193 kb
File Type: pdf
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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​ [Fillable form as of 10/4/2022.]
authorization_for_disclosure_100422.pdf
File Size: 204 kb
File Type: pdf
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autorizacion_de_divulgacion_100422.pdf
File Size: 224 kb
File Type: pdf
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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​ [Fillable form as of 10/4/2022.]
card_on_file_100422.pdf
File Size: 119 kb
File Type: pdf
Download File

tarjeta_en_archivo_100422.pdf
File Size: 125 kb
File Type: pdf
Download File

LMFT #113688
​Concord Business License #5022539

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