Client Forms

The following forms are meant to help you save time in beginning therapy with Karen Pierpoint. They will also help you exercise your rights and responsibilities as a client.

Download, print and fill out the appropriate forms before your initial visit. If you do not have the capability of downloading the forms, let Karen Pierpoint know when you make your first appointment. She will make the forms you need available for you in the waiting area. Please arrive 15–20 minutes early if you need to complete them at that time.

Guidelines & Policies (PDF)
Before treatment may commence you are requested to read the following guidelines.

Client Information Form (PDF)
This form will give Karen Pierpoint the information she needs in order to set up your client records and insurance billing.

Informed Consent for Treatment and/or Evaluation (PDF)
This form must be signed before therapy can begin. It gives Karen Pierpoint authorization to become your therapist, and it indicates that you have read her office guidelines and policies and agree to treatment consistent with those policies.

Authorization for Release of Information (PDF)
Please fill out this form if you have another doctor or therapist whom you would like Karen Pierpoint to contact to obtain or give information about your diagnosis, treatment, prognosis, or history. You can specify to whom the information should be released, and what type of information can be shared. Karen Pierpoint strongly believes that collaboration among all those treating a client makes for the most successful client care.

HIPAA Patient Privacy Notification (PDF)
This serves as your notification of your rights to privacy under the Health Care Information Portability and Accountability Act. Federal law requires Karen Pierpoint to provide this notification, which is written the way most government paper work is written. Do not despair. Just print this notification out, and keep it for your records.

Receipt of Patient Privacy Notification (PDF)
Please sign this form to indicate that you have received a copy of the HIPAA Patient Privacy Notification, and bring the signed form to the initial visit so that Karen Pierpoint can include it in your file.