Welcome to Burlington Psychological Associates. You will be asked to complete the following documents on the day you arrive for your initial appointment. They are here for your review.  If you have access to a printer, please complete and bring these forms with you to your first appointment.

1. Contact Information – Please be sure to provide your full name, date of birth, and current address.  In addition, provide any phone numbers you would like to be contacted on and indicate if a message can be left for you at that number.

2. Please review our notice of privacy practices (HIPAA), once you have reviewed the document please print and sign the notice of privacy practices – acknowledgement form indicating that you received a copy of the HIPAA regulations.  You may ask for an additional copy of the HIPAA regulations or access it here at any time.

3. Medical Release and Assignment of Benefits – This form allows your provider at Burlington Psychological to submit information to your insurance company for billing purposes.  Please fill out your clinicians name in the first two blank spaces, and sign and date each of the sections.  This document includes statements that allow your clinician to submit documentation to insurance companies, an acknowledgment of cancellation policy, and a general statement of how protected health information is transmitted.

4. Consent to use text and email – Please complete this form for any phone number or email address that you would like use for communication with your clinician.

5.  Stress Questionnaire – Please complete this form prior to your first appointment.

Please feel free to contact our office with any questions regarding the forms provided.