Please print out each of the following forms, fill them in, and bring them with you to your first appointment. If you are scheduled for a telehealth appointment, please make sure we receive them prior to your appointment. You can drop them off, mail them, or fax them to our office. We do not accept email.
Patient Information Form (in PDF)
Please fill out this Patient Information Form as best as you can and bring it to the initial appointment.
Notice of Privacy Practices (in PDF)
Acknowledgement of Receipt Form
Please sign and date this form. It acknowledges that you received a copy of the Privacy Policy.
Release of Information Form
This form, when completed and signed by you, authorizes me to release protected information from your clinical record to the person(s) you designate. Please include your emergency contact person.
Psychiatrist-Patient Service Agreement
Kissing Bridge, Waterville, Vermont
Painting by Bill Schmidt