Initial paperwork- please read and/or fill out ALL forms
AND bring to your first session.
You must bring your current insurance card at intake.
Please print and fill out these forms
| Client Intake Form |
| acknowledgement page |
| Insurance Form |
| Functioning Assessment- pls complete |
| HIPAA- sign last page |
| consent to working w therapy dog |
Please read each of these documents. Let me know if you have any questions at your intake appointment.
| Client Rights |
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The most recent financial policies can be found under rates/insurance webpage.
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| Medicaid Privacy Rights |
| Professional Disclosure Statement |
Electronic Health Record
I use www.therapyappointment.com for my electronic health records [Link below]. You can receive an email, text or phone call reminder for your appointments. Please let me know what you prefer. To create an account, send a secure email or edit information, please click below. I can be found under Find Therapist- Eng. If you have scheduled an intake appointment, please go ahead and fill out the new patient information. Thanks! I look forward to meeting you.
I use www.therapyappointment.com for my electronic health records [Link below]. You can receive an email, text or phone call reminder for your appointments. Please let me know what you prefer. To create an account, send a secure email or edit information, please click below. I can be found under Find Therapist- Eng. If you have scheduled an intake appointment, please go ahead and fill out the new patient information. Thanks! I look forward to meeting you.
POLICY ON SOCIAL MEDIA & ELECTRONIC COMMUNICATION
SOCIAL MEDIA
I am committed to maintaining proper boundaries that include, but are not limited to, protecting the privacy and confidentiality of the therapeutic relationship. Therefore, it is not my practice to accept “friend” or contact requests from current or former clients on any social networking site. Please do not use social media sites to contact me as I do not check these sites regularly (Linked In, Facebook, etc...). I also make a commitment not to research your social media information and ask that you not search my private social media. I welcome you to join my private practice Facebook page at Debra Eng, LCSW, PLLC or search my website at www.debraeng.com.
EMAIL
I use VIRTRU for secure, encrypted email. You do not have to subscribe to use VIRTRU. You will need to confirm your email address to read my emails. This protects your Personal Health Information (PHI). This security is required to be HIPAA compliant. Please note that text messages and regular email are not secure forms of communication. If you choose not to receive secure email through VIRTRU or Therapy Appointment Portal, please provide a request in writing.
I generally prefer to limit use of email to arrange and modify appointments. I will not process or conduct sessions via email. You may provide information to me to address in session via email. I will acknowledge receipt this information to address in session but may not provide a detailed response.
Please do not use email for emergencies. Any of our emails may be retained in your records. If you send an email regarding an appointment and do not hear from me within 24 hours, please call and leave a voicemail message.
TEXTING
The phone number provided is a cell number, the above listed parameters apply to texting as well. Please note that cell phones are not a secure means of communication. Please do not include me in group text. Please do not send texts outside of normal business hours except in case of emergency (9a-6p Monday-Friday).
SOCIAL MEDIA
I am committed to maintaining proper boundaries that include, but are not limited to, protecting the privacy and confidentiality of the therapeutic relationship. Therefore, it is not my practice to accept “friend” or contact requests from current or former clients on any social networking site. Please do not use social media sites to contact me as I do not check these sites regularly (Linked In, Facebook, etc...). I also make a commitment not to research your social media information and ask that you not search my private social media. I welcome you to join my private practice Facebook page at Debra Eng, LCSW, PLLC or search my website at www.debraeng.com.
I use VIRTRU for secure, encrypted email. You do not have to subscribe to use VIRTRU. You will need to confirm your email address to read my emails. This protects your Personal Health Information (PHI). This security is required to be HIPAA compliant. Please note that text messages and regular email are not secure forms of communication. If you choose not to receive secure email through VIRTRU or Therapy Appointment Portal, please provide a request in writing.
I generally prefer to limit use of email to arrange and modify appointments. I will not process or conduct sessions via email. You may provide information to me to address in session via email. I will acknowledge receipt this information to address in session but may not provide a detailed response.
Please do not use email for emergencies. Any of our emails may be retained in your records. If you send an email regarding an appointment and do not hear from me within 24 hours, please call and leave a voicemail message.
TEXTING
The phone number provided is a cell number, the above listed parameters apply to texting as well. Please note that cell phones are not a secure means of communication. Please do not include me in group text. Please do not send texts outside of normal business hours except in case of emergency (9a-6p Monday-Friday).
©2018 Debra Eng, LCSW, PLLC
Paperwork may not be reproduced without permission