Essential Forms

Essential Forms

Please read carefully and bring all required documents to your first session. This is critical for our office to best serve you. Thank you!

Bring the following completed form to the first session or fax the day before to Psyche Associates at 303-617-3668. If you are using insurance or EAP, bring a copy of the front and back of your insurance card and check below for any additional forms required by your specific insurance company.

New Client Intake Form

Your signature on the above Intake Form indicates you have read and agree with my office policies including my cancellation policy. Here is a copy for you to read before our first session:

Office Policies & General Information Agreement for Psychotherapy Services

HIPAA Notice of Privacy Practices

Telehealth Consent Form:

Consent to Participate in a Telemedicine Consultation

Insurance and EAP Forms:

Waiver of Insurance Billing

Advance Beneficiary Notice for Non-Covered Services

Additional Insurance and EAP Forms – If your insurance company’s form is listed below, complete and bring this with you to your first session along with the Intake Form and copy of insurance card.

United Behavioral Health Wellness Assessment Form

Anthem Blue Cross EAP Patient Signature Form

United Behavioral Health EAP Statement of Understanding Form

EAP Self-Referral Waiver

Anthem Member Grievance and Appeal Forms:

Grievance/Complaint Form Instruction Sheet

CDI English Grievance Documents

CA Member Grievance Form (English)

DMHC Enlgish Grievance Documents

If you would like us to be able to communicate with your PCP or other health care professional about you, also bring this form to your first session:

Authorization Consenting to Release of Information