Dr. Jacobson
My Private Practice
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Printable Stuff (Forms)


Right click (or control click for Mac) the icons below to open and print forms.

For most new clients, you will want to print out Directions, Registration and Therapy Contract

The Directions will help guide you to my office, help you locate my office in the complex and how to use the electronic notifier to let me know when you have arrived.

Fill out the Registration form and bring it to the initial session with your insurance card.  I strongly suggest calling your insurance company prior to the first session to clarify your insurance coverage, including whether I am in network or out of network, the amount of your annual deductible and what your copayment will be for each session.

Print, read and sign the Therapy Contract, and bring that to the session as well.

The Release of Information should be printed and filled out only if you know that you are going to want me to share information with, or get information from, another professional who is or was involved in your care.  If you are unsure, just skip this and we can decide together in the first few appointments.

 


 


Directions to my Office

Download jacobson Directions_to_Office.pdf

Registration Form

Download Registration Form new.pdf

Therapy Contract

Download HIPAATherapyContract.pdf

Release of Information Form

Download release form KAJ.doc