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Forms

Welcome to the forms and other information section of this website.  Below you will find and explanation of each form, my cancellation policy, confidentiality, payment and information about sole proprietorship.  If you do not see the information you need, please feel free to contact the office directly.

Forms and Information about Each Form

If you have scheduled an appointment, please complete the following forms and bring them with you for your initial appointment.  If you do not complete these forms in advance, you will need to arrange to come in 30 minutes prior to your appointment so they can be completed before your appointment time.

The forms that everyone needs to complete are:

Intake Form- a form about your personal history.  Please complete as thoroughly as possible.  However, if details are difficult to put down or hard to talk about know we can discuss them in sessions instead.  Please complete form and sign and date the bottom.  Bring this with you to your first appointment completed.

Informed Consent– a form which lets you know about office policy and confidentiality.  Please read, sign and date this form.  Bring this with you to your first appointment.  You can print a copy out for your own records as well if desired.

Other forms that may be needed depending on your case include:

Release of Authorization- fill out this form if you will be needing me to release confidential information to anyone (i.e. social worker, insurance company, doctor, family member, etc.).  Because your therapy information is confidential health information, a release must be completed if you need me to release information to anyone else.  Read more about confidentiality by clicking here.

Debit/Credit Card Preauthorization Form– Complete this form if you would need to set up credit/debit card payment by a third party or want to take care of payment by credit card without using your session time to process the payment.  Please make sure the person who will be using their credit card to pay for sessions (cardholder) signs this form as well as the person receiving therapy (client).  Please talk with me in session if you are not sure if this form is necessary (i.e. you wish to pay at the time of service by credit card or any other situation).

Be sure to bring your completed forms to your first appointment.  If you cannot do so, arrange to come in and fill them out 30 minutes prior to your first appointment.  Coming in early must be arranged in advance.  Please feel free to call the office if you have any questions about these forms. 

 

Other Important Information 

Cancellation Policy:

It is my policy to charge for appointments booked unless they are cancelled at least 48 hours or 2 business days in advance. (i.e. an appointment at 2:30 pm on Wednesday must be cancelled at or before 2:30 pm on Monday to avoid being billed, an appointment at 10 am on Monday must be cancelled by 10 am on Thursday, etc.)  When an appointment is booked that time is not available to other clients, meetings or other activities.  Please let me know in advance if you cannot keep your appointment.

Confidentiality

By law and professional ethics, your sessions are strictly confidential.  Generally, no information will be shared with anyone without your written permission.  There are, however, a number of exceptions to this confidentiality policy.

If you report that you or another person has been the victim of child abuse, I am required by law to report this to the authorities investigating child abuse.

If you report that you or another person has been the victim of elder or dependent adult abuse, I am required by law to report this to Adult Protective Services or other appropriate authorities.

If you threaten to seriously harm yourself or someone else, I may be required to take one or more or the following steps: contact police, warn the potential victim, or take other reasonable steps to prevent the threatened harm.

If you sign a release of information requesting and authorizing me to discuss or verify your participation or other treatment information.

If I am ordered by the court to testify or release records.  In this situation, I may be required to give a summary of the case records whether or not a release of confidentiality was signed.

The other possible exception to complete confidentiality would become relevant if I should need to seek consultation from colleagues regarding your case.  If this should be necessary, I will not use your name or any combination of identifying data that would make it likely that your identity would be ascertained by others.

Payment

I accept checks, cash and credit cards for payment. Please be prepared to pay for sessions at the time of service unless you have made other arrangements in advance.  It is often easiest to process payment at the beginning of session so we can focus on your session fully for the remainder of the appointment time.

Notice of IRC Subchapter S Corporate Ownership

Please be aware that Alice Petty-Hannum, MFT is a business held and owned by an IRC Subchapter S Corporation; Bridges to Self-Empowerment, A Marriage and Family Therapy Corporation.  Alice Petty-Hannum, MFT is managed solely by Alice Petty-Hannum.  This IRC Subchapter S Corporation is family owned and there are no other partnerships or affiliations with others who occupy office suites at 406 Chinn Street, Santa Rosa or any other location.

Downloadable forms:

 

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