Forms

These forms are completed during the initial visit.  In order to make the most of this time, it is helpful if you can complete these forms in advance and bring them with you to your first visit.

Please click on the respective forms to download them. They will open in a new window.

• Client Information Form
• Notice of Privacy Practices - HIPAA Federal Form
• Notice of Privacy Practices – HIPAA New York Form
• Email Consent Form
• Waiver of Health Insurance Form

Please note: Insurance companies require the designation of a clinical diagnosis. This information becomes a part of insurance companies' data banks. Dr. DeSole cannot control what is done with this information. In addition, insurance companies may request additional information regarding symptoms, compliance, progress updates, expected outcomes and anticipated length of treatment, via forms, e.g., an Outpatient Treatment Form, or telephone interviews. As a result, individuals may choose to opt out of using their insurance for payment.