Forms

 

Here you will find many of the forms we use in our practice.  We ask that you download and complete those that are requested by your clinician prior to your appointment. If for some reason this is not possible, kindly arrive 15-20 minutes prior to your appointment time in order to fill out the forms.

GENERAL FORMS                                                

policy_practices

ChildIntakeForm1

Notice-of-Privacy-Practices

ClientAgreementcoach

InformationTenBigQuestions

Notice-of-Privacy-Practices

Privacy-Practices

Consent-Minor

Request for IEE Information

Consent ( to release information )

CreditAuthorization

SessionPrepForm

ConsultSessionPrepForm

ClientAgreementconsult

Ten90DayGoals

 COACHING FORMS                 

ChildIntakeForm1

ClientAgreementcoach

SessionPrepForm

TenBigQuestions

Ten90DayGoals

policy_practices

Notice-of-Privacy-Practices

Privacy-Practices

Consent-Minor

Consent (to release information)

CreditAuthorization

ADVOCACY FORMS  

Notice-of-Privacy-Practices

Privacy-Practices

policy_practices

ClientAgreementconsult

ConsultSessionPrepForm

CreditAuthorization

Consent   (to release information)

EVALUATION FORMS

ChildIntakeForm1

policy_practices

Notice-of-Privacy-Practices

Privacy-Practices

Consent (to release information)

Consent-Minor

CreditAuthorization

Request for IEE

At this time we are not in network providers for any insurance. However, you are more than welcome to contact your insurance company to find out if you have out of network benefits. We will be happy to provide you with the diagnostic and evaluation codes you might need for reimbursement. Contact us for more information. All records are maintained for five years after the last date of service. Copies of evaluations older than two years are archived. Please allow 2-4 weeks from date of request to receive a copy of your evaluation.

At Rich Educational Consulting, we strive to accommodate our clients’ busy schedules. We offer weekend and evening appointments as well. We expect the same consideration for our time and schedules from our clients. Please be advised that any appointments cancelled with less than 24 hours notice may be subject to a $150.00 cancellation fee. If more than one service provider is involved, the fee will apply to each service provider. For IEE clients, this fee is at parent, not district expense.  For concerns regarding your specific situation, please reference our forms or contact us directly.