New Patient Information and Intake Forms

Please review my privacy policies (HIPAA). I also need to collect some basic information so that I can contact you during the normal course of treatment, or in an emergency. The information you enter here is confidential and I will request your consent before sharing this information unless emergency circumstances make it impossible for me to do so. 

Privacy Policies

I am required to follow the privacy practices described in the Health Insurance Portability and Accountability Act (HIPAA). I am also required to follow the Ethics Code of the American Psychological Association (APA), and to honor your confidentiality to the greatest extent possible. Unless an emergency, or court order make it impossible, I will always consult you prior to the release of your personal information. Please ask me if you would like to discuss the privacy practices described below in more detail, or if you would like a paper copy of these policies.

HIPAA Based Privacy Practices


New Patient Intake Form

Name
Name
Address
Address
Date of Birth
Date of Birth
Mobile Phone
Mobile Phone
May I leave a message on your mobile phone?
Home Phone
Home Phone
May I leave a message on your home phone?
Emergency Contact
Emergency Contact
Privacy Practices (HIPAA) *
I have been notified of the privacy practices of Dr. Seth J Dennis.