Documents and Forms

Below you will find some important documents to review and forms to complete before getting started in psychotherapy with Dr. Bear Korngold.

1

Review

Please read the Policies & Consent and Notice of Privacy Practices documents below and let me know if you have any questions or concerns.

2

Complete & Sign

Then print, fill out and sign the Patient Information and Ackowledgement forms and bring them with you to your first session.

Policies & Consent

This document outlines my office policies and serves as an agreement between therapist and patient to engage in psychotherapy.Download Document

Privacy Practices

This notice explains privacy practices with regard to your medical information. It explains your rights and protections related to the use and disclosure of your health care information.Download Document

Patient Information

This document is to be filled out with each new patient’s contact information and history of previous treatment. You may also fill this form out online.
Download Document

Acknowledgement

Acknowledgement that you have ongoing access to and have read my Office Policies and Notice of Privacy Practices and that you consent to treatment. You may also fill this form out online.Download Document

Supplemental

These documents are optional and provide a means for communication with other providers or making separate arrangements for payment of services.

Release of Information

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please print out and complete this document and bring or fax it to me. Please let me know if you have any questions regarding this Release of Information.Download Document

Third-Party Payer

This document allows for a third-party to be responsible for the payment of psychotherapy services for a given patient while protecting the privacy of the patient in treatment. It will need to be signed by both the patient and the third-party payer.Download Document

If you are unable to download, print and fill out these documents, please let me know and we can arrange for them to be filled out at the office prior to our first appointment.

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