General Instructions for Forms
Please complete the forms online using the online form links below. Please submit them by the evening before our appointment to give me time to look through them before our session.
All Information that is submitted using the online forms is encrypted and secure to protect your sensitive data.
Initial Assessment Forms
The following forms all need to be completed for our first session – the Initial Assessment Form, the Patient Information Sheet and the HIPAA Privacy Information & Confidentiality Form.
Please click on the links below to complete the forms by either printing, completing by hand and bring to our first appointment or submitting information using the online forms prior to our first appointment.
Assessment Questionnaire Print
Assessment Questionnaire Online form
Patient Information Sheet Print
Patient Information Online form
HIPAA – Privacy of Information Policies Print
HIPAA – Privacy of Information Policies Online form
Symptom Checklists
Please complete any of the mood inventories below that are relevant to your symptoms.
Please note that these checklists are part of Dr. Allen’s assessment for new clients and are not meant as a diagnostic tool for people who are not Dr. Allen’s clients. The completed checklist results are only available to Dr. Allen due to HIPAA compliance rules.
Depression Symptoms Scale PHQ-9 Print
Depression Symptoms Scale PHQ-9 Online Form
Anxiety Symptoms Questionnaire GAD-7 Print
Anxiety Symptoms Questionnaire GAD-7 Online Form
Trauma Questionnaire Impact of Events Scale Print
Trauma Questionnaire Impact of Events Scale Online Form
Pregnancy & Postpartum Mood Screening Test Print
Pregnancy & Postpartum Mood Screening Test Online Form
Perinatal Anxiety Screening Test Print
Perinatal Anxiety Screening Test Online Form
Credit Card Payment Authorization
Please use this form if you would like to authorize session payments using your credit or debit card. I use a credit card system through Chase bank that securely keeps your information on file to be accessed for the session fee after each session. This means you do not have to complete the information at every session. I accept Visa & Mastercard.
Amex is not accepted at this time.
Credit Card Payment Authorization Form Print
Credit Card Payment Authorization Online Form
Remote Sessions Using Teletherapy
If you wish to have our appointments using Teletherapy you must complete the Teletherapy Consent form. More information about appointments via telephone or using VSEE which is a HIPAA compliant “skype-like” platform can be found on the Telephone or Online Sessions page.
Teletherapy Consent Form Print
Teletherapy Consent Form Online Form
Using Medical Insurance Benefits
If you would like me to submit your insurance claim to your insurance company electronically on your behalf please download the Insurance Submission form below.
Alternatively, I can provide you with a monthly statement called a Superbill which is a detailed receipt that you submit yourself and provides all the information insurance companies need to create a claim and you can potentially get some reimbursement.
Insurance Submission Form Print
Insurance Submission Online Form
General Forms
Consent To Communicate With Your Other Healthcare Providers
Please complete the Consent to Release Information Form below if you would like me to be able to communicate or release information regarding your therapy to other doctors or for disability records.
Release of Information Consent Form Print
Release of Information Consent Online Form
Weekly Unhelpful Thought Diaries
An important part of Cognitive Therapy is keeping track of unhelpful thoughts (also called cognitions). Together we will look at where theses types of thoughts come from, how they are holding us back and how to reframe them in a way that improves mood. The Thought Diary can be downloaded below and gives a structured way to identify unhelpful negative thoughts. Side 2 gives a list of questions that help us challenge these unhelpful negative thoughts.