Forms
Forms are an important part of getting started.
Please fill out this general information form and bring it to your first session. Also, please print out, sign and bring this form: Disclosure Statement and if need be, Tele Psychotherapy Disclosure Statement to your first session. Note: in this time of virtual visits please download, print these forms, sign them and send them via email to [email protected].
Notice of Privacy Practices
A federal law called HIPAA requires that I take specific steps to keep you informed about how I may use information that is gathered in order to provide health care services to you. As part of this process, I am required to provide you with the attached Notice of Privacy Practices and to request that you sign the written acknowledgement that you have revived a copy of this notice. This Notice describes how I may use and disclose your protected health information for purposes of treatment, payment, and other purposes that are required or permitted by the law. This Notice also explains your rights regarding your protected health information that I keep in my clinical records and describes how you may execute these rights. Please ask me any questions that you might have regarding this Notice. There are links on my website to forms to assist you in executing these rights, should you feel the need.
I take every reasonable step to ensure the safety of your information, both paper, and electronic. Although I use an encrypted, fire walled, and passworded email and computer, there are risks associated with it, and texting is inherently insecure. If you choose to communicate with me in these ways, understand that there is no way to guarantee your privacy.
Summary of Forms:
- General information form
- Disclosure Statement
- Tele Psychotherapy Disclosure Statement
- [email protected]
- Notice of Privacy
Please read and sign the HIPPA Right to Privacy Statement.. .
Other HIPAA/State law compliant forms:
- Authorization to Exchange Confidential Information
- Collateral to Therapy
- Patient Request for Restriction on Use and Disclosure of PHI
- Request for Amendment of Health Information
- Complaint Form
If you prefer, you can mail these forms to:
Barbara Rose Chateaubriand
1424 NE 155th St #209
Shoreline, WA 98155
Texting is not HIPPA secure, so I use a chat option on my videoconferencing platform, VSee.
These forms may also be filled out and brought with you to your initial appointment.
If you prefer, you can mail these forms to:
Barbara Rose Chateaubriand
1424 NE 155th St #209
Shoreline, WA 98155