Forms

I am currently unable to accept new clients.

Below are forms that were used in the past.

Client Information PLEASE COMPLETE

Updated Notice of Privacy Services Please Keep copy for your records

HIPAA acknowledgment of receipt please sign

Medical history Please print and complete

Presenting Concern Adult Self-Report Please Complete

COMPREHENSIVE VERSION OF CONSENT TO TREATMENT

Each client is asked to review and sign a copy of Consent to Treatment (please see above), which is a shortened version of the original Comprehensive Consent to Treatment (with the goal of saving trees). By signing the shortened version, each client consents to the stipulations and conditions of the Comprehensive Consent to Treatment, which can be accessed below or requested directly from Dr. Ostoja.

COMPREHENSIVE CONSENT TO TREATMENT DO NOT PRINT