Dr. Bert H. Epstein, Psy.D.
This form explains my office procedures and includes an agreement for psychotherapy services. The document also includes important information about your confidentiality. If you have questions after reading this form, please bring them up when we meet.
I am required by law to provide you with a copy this HIPPA Notice of Privacy Practices so you can understand your rights and protections related to the use and disclosure of your identifiable health care information.
This forms reviews important information regarding tele-health sessions.
My social Media Policy explains my policies as they relate to our potential interactions on the Internet. Please let me know if you have questions or concerns about these policies.
PLEASE PRINT, COMPLETE, AND BRING TO YOUR FIRST SESSION(Note: The below links are fillable pdfs. Instructions to save your work are as follows:
1. Download the form(s) blank to your computer. 2. On version that is downloaded, click File, then Save As Other
3. Choose Reader Extender PDF, and then Enable More Tools.
4. Save this version, and now it will save the information you type into it, so that you can email this version to me.
5. When done delete the information from your computer for confidentiality.
Once you have read all four forms above (Policies, Privacy, Tele-Health, and Social Media), please sign the acknowledgement form. This states that you have read and agreed to the information on all these forms. IMPORTANT: Prior to our first session, email this form to me.
Prior to our first session, please complete my Client Information Sheet and email it to me. This will help you share important details with me and speed up the process of my getting to know you.
IF you would like me to coordinate with another provider (for example, your psychiatrist or primary care physician), please complete this form and email to me.