Patient Forms

 

Before your appointment Please read and fill out the following forms before your first meeting.

 

To download all forms in the original format, please click 'DOWNLOAD ALL FORMS' button below.

 

If you are a new client you can review and complete the following forms and bring them with you to your first session:

 

After the form opens, you may save it in your computer by clicking the 'Save As' button on your browser. You may also print them directly from your computer by selecting 'Print'.

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All information between therapist and patient is held strictly confidential unless:

1. The patient authorizes release of information with his/her signature.

2. The patient presents a physical danger to self.

3. The patient presents a physical danger to others.

4. Child/elder abuse/neglect is suspected.In the latter two cases, I am required by law to inform potential victims and legalauthorities so that protective measures can be taken.

 

Upon verification of health plan,insurance coverage and policy limits, your insurancecarrier will be billed for you and your provider will be paid directly by the carrier. Thepatient/guardian will be responsible for any applicable deductibles and co-payments. Ifyou are not eligible at the time services are rendered,you are responsible for payment.

 

A scheduled appointment means that time is reserved only for you. If an appointment ismissed or canceled with less than 24 hours notice, the responsible party will be billedaccording to the scheduled fee or according to the rules of the patient's health plan.

 

I understand that I have a right to request reconsideration in the case that outpatient careis not authorized. I understand that the request for appeal can be made through myProvider and that I risk nothing in exercising that right.I also understand that I have a right to submit a complaint/grievance and risk nothing to exercise that right. I understand that to submit a complaint or grievance, I may contact theCustomer Service department of my Health Plan.

 

I further authorize and request that Dr. Stephanie R. Baron, Ph.D. carry out psychologicalexaminations, treatments and/or diagnostic procedures that now or during the course ofmy care as a patient are advisable. I understand that the purpose of these procedures willbe explained to me upon my request and Subject to my agreement. I also understand thatwhile the course of therapy is designed to be helpful,it may, at times, be difficult anduncomfortable.

 

Stephanie R. Baron, Ph.D.Lic. #PSY 1197210444 Santa Monica Blvd., Suite 302, Los Angeles, CA 90025

 

I authorize the release of information for claims, certification,case management,qualityimprovement, and other purposed related to benefits of my Health Plan. I understand andagree to all of the above information.

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Copyright 2017. Stephanie R. Baron, PhD. All rights reserved

Stephanie R. Baron, PhD.

EMDRIA APPROVED CONSULTANT

EMDR Certified therapist

Stephanie R. Baron, PhD.

 

EMDRIA APPROVED CONSULTANT

EMDR Certified therapist