David I. Brandt,  - Psychoanalysis • Psychotherapy • Counseling
 
Forms
 
 
 
Below, please find various forms that I may need you to sign, or fill out.  They are available for your convenience, as needed, once you are in psychotherapy.

 

This form is usually given out during the first session and is both required by the state as part of your record AND very helpful to me in getting to know you better.
 
This agreement puts in writing our mutual understanding regarding my taking what is called "assignment" from your insurance company.  Assignment is explained under the Insurance tab of this web-site, as well as by reading the agreement itself.
 
When I need permission from you to speak to someone involved in your or your child's treatment (e.g., a relative, psychiatrist, other psychologist or psychotherapist, teacher, etc.), I will ask you to review and sign this form so that we have a clear mutual understanding about what will be disclosed. Often, you will also need to sign the equivalent form with the other party.
 
This agreement allows me to work with patients who are on Medicare, and yet opt out of Medicare's plan.  It also enables Medicare patients to use their secondary insurance, if any, under the circumstances of my opting out.  I am happy to explain this agreement in person or by phone.
 
This form provides the information I need to electronically bill for you.  Please fill out the top section completely and sign in the two places indicated, if they apply.