Client Forms
Client Forms
If you are a new patient, please fill out and submit the correct forms before your first session.
Forms - Policy
Forms must be submitted at least 48 hours before your first appointment. This will allow me to spend as much time as possible focusing on you during our initial sessions.
If you don't return your forms 48 hours before your first appointment, your session will be rescheduled.
You may be asked to complete extra forms or assessments based on your needs and goals.
Forms - Privacy
Forms submitted through this website are sent through a HIPAA-compliant system. Using this system allows us to protect your personal information and confidentiality. Please submit all forms through the links below.
When minors contact me
Please note, in the state of Pennsylvania, minors ages 14 and up may seek out and receive mental health treatment without parental consent.
For more information about minors seeking medical and mental health care, you can read this guide by the ACLU.
Online Forms
Please click on the link for the form you need. Once you fill it out, please click the button marked "submit."
I'll receive the completed form within 24 hours.
Thank you.
General Forms
- BCAC New Patient Intake Form + HIPAA Form
- BCAC Policies and Procedures Form
- BCAC Informed Consent for Phone and Online Therapy
- BCAC Credit Card Authorization Form
- BCAC Release of Information Form
- BCAC Revocation of Authorization Form
- Medicaid Waiver Form
BCAC HIPAA (Patient Privacy) Policy
Below is a copy of the HIPAA/Privacy statement.
Please read this before your first session and sign the HIPAA Acknowledgement/Consent form that is part of the New Patient Intake.
You can access this privacy statement at any time.
Release of Information Forms for Drug and Alcohol Related Information
- BCAC Release of Information Form - Drug and Alcohol Use Information and Records
- BCAC Release of Information Form – To a Treatment Provider – Drug and Alcohol Information and Records