Forms 

For your convenience, I have provided the following forms in downloadable, printable versions to make getting started and accessing treatment easier. Please complete these forms and bring them to your first appointment.

Forms needed for your first session. Adult patients do NOT need to complete a History Form

 

1. Intake Paperwork. These are the basic information and consent forms needed to begin treatment with Dr. Goldner. In the case of a minor child (under 18 years of age), when possible, it is encouraged that both parents/legal guardians sign these forms regardless of marital status or divorce. However, one parent may initiate treatment alone without the consent of the other parent in accordance with state law. Note: Filling out these forms alone does not create a therapeutic contract or therapeutic relationship. An intake session must be completed and Dr. Goldner must agree to treat the individual as an ongoing client in order to initiate treatment. Only one parent must be present at the intake session in order to initiate treatment.

 

2. Symptom Checklist. This is a general symptom checklist suitable for children and adults.

 

3. Child History Form. This is a detailed questionnaire that is required for new child and adolescent clients. Adult clients may choose to fill out this form, but in my experience Adults are typically able to provide this kind of detailed information during their first session. Bringing a completed History Form with you to your first session will save time during the intake process.

 

4. Release of Information Form. Any client information you give me, even the very fact that you come to see me for treatment, is privileged and confidential. I require a completed Release of Information Form before I can discuss your or your child's case with anyone, including teachers, administrators, physicians, and other helping professionals. 

 

5. Notice of Privacy Practices. As a client, your privacy is protected by numerous laws, rules, and ethical regulations (HIPAA - Health Insurance Portability and Accountability Act). The Notice of Privacy Practices is a detailed explanation of a client's privacy rights.

 

 

 

For more information about Dr. Goldner or his practice, please click on the tabs to the left of this page. If you have a question that is not answered on this website, please feel free to contact Dr. Goldner directly by Email or Phone.