Forms here are provided for your convenience, but may also be filled out at your first appointment.
There may be additional forms required, not provided here. Each person will need to fill out appropriate forms, prior to treatment. You will also need to show
proof of identification and/or legal authorization to obtain treatment for minors. All forms are subject to change without notice. Please contact Miranda for most up-to-date fee scale. Fee scale subject to change. Payments are always due at the beginning of a session.
A copy of state issued ID (Driver's License or school ID for minors) is required at the first appointment.
A copy of the most current court decree is also required at the initial appointment, for divorced parents or legal guardians for treatment of all minors.
For Individual or Couple Therapy, you will need to print and complete: 1 "Individual Intake" form for each person, 1 "Information and Consent for Individual or Couple Therapy", 1 "Current Sliding Scale Fee," 1 "HIPPA" and 1 "Minor Treatment Policy" if the client is under 18 at the time of the first appointment.
For Family Therapy, you will need to print and complete: 1 "Individual Intake" form for each person, 1 "Information and Consent for Family Therapy", 1 "Current Sliding Scale Fee," 1 "HIPPA" and 1 "Minor Treatment Policy" if the client is under 18 at the time of the first appointment.
Release forms are optional. One specifically created for use by patients of Mary Becton-Crouse is provided, another blank form for patients of other places, or for other individuals is also provided here.
proof of identification and/or legal authorization to obtain treatment for minors. All forms are subject to change without notice. Please contact Miranda for most up-to-date fee scale. Fee scale subject to change. Payments are always due at the beginning of a session.
A copy of state issued ID (Driver's License or school ID for minors) is required at the first appointment.
A copy of the most current court decree is also required at the initial appointment, for divorced parents or legal guardians for treatment of all minors.
For Individual or Couple Therapy, you will need to print and complete: 1 "Individual Intake" form for each person, 1 "Information and Consent for Individual or Couple Therapy", 1 "Current Sliding Scale Fee," 1 "HIPPA" and 1 "Minor Treatment Policy" if the client is under 18 at the time of the first appointment.
For Family Therapy, you will need to print and complete: 1 "Individual Intake" form for each person, 1 "Information and Consent for Family Therapy", 1 "Current Sliding Scale Fee," 1 "HIPPA" and 1 "Minor Treatment Policy" if the client is under 18 at the time of the first appointment.
Release forms are optional. One specifically created for use by patients of Mary Becton-Crouse is provided, another blank form for patients of other places, or for other individuals is also provided here.
intake_1_for_individual_9.14.pdf | |
File Size: | 216 kb |
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intake_2_information_and_consent_form_1.14_ind_cple.pdf | |
File Size: | 150 kb |
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intake_2_information_and_consent_form_7.14_family.pdf | |
File Size: | 174 kb |
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intake_4_sliding_scale_fee_mt_1.14.pdf | |
File Size: | 159 kb |
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HIPPA 11.12 | |
File Size: | 137 kb |
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intake_6_treatment_of_minors_policy_mt__7.14.pdf | |
File Size: | 140 kb |
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release_blank_-_7.14.pdf | |
File Size: | 209 kb |
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