FORMS FOR NEW CLIENTS 
TO FILL OUT


Welcome. If you're coming in for the first time, please review, complete and sign (if necessary) the following forms, then bring them to your first session. This will make our first session more productive (and less expensive for you - if you give me this initial information before we start, we won't have to waste a session or two getting this information).

 

Simply click onto the name of the form, download your copy, print out a copy, read, complete and/or sign the form and bring it into your 1st session. If you have sessions via Skype please complete the forms and email them back to dave@acceleratedhealingsolutions.com or mail it to me via snail mail at 128 Radio Circle, Mt. Kisco, N.Y. 10507.
 

Client Intake Form

 

       Please complete this form and bring it into your 1st session 

 

Confidentiality & limits thereof

       Please read and sign this form before your 1st session

 

Cancellation Policy

       Please read and sign this form before your 1st session

 

H.I.P.P.A. Regulations 

       Please read and sign this form before your 1st session 

 

Policy and Procedures 

       Very important to read in entirety, download, sign and bring in 
       signed page to your 1st session   

 

Your Treatment Plan (issues that you want to work on)

 

       For you to think about right now. We will work with this treatment 
       plan more thoroughly in the future but it would be good for you to 
       start thinking about some of these things that you wish to work on.

 

If you would like me to coordinate your care with another provider (i.e., your psychiatrist, endocrinologist, etc.), please complete this form:

 

Consent to Release Information Form

 

 


                     Note: To download Adobe Acrobat Reader for free, click here. 

 

Dave Dodge, L.C.S.W.
Mt. Kisco, N.Y.
(914) 242-3484
Skype and telephone sessions are also available
Skype name - dave.dodge11

Please also visit my other website for more information on how I can help you.

I am a therapist with over 40 years of experience working with people to help them resolve the issues that are creating problems in their life. I am Certified and trained in a number of alternative therapies that are quicker, easier and much more effective than talk therapy in releasing one's issues.