Marcia Johnston Wood, Ph.D.

Marcia Johnston Wood, Ph.D. -

Forms

Once we have set up an initial session time, prior to this first meeting please download and completely fill out copies of each of the relevant forms. Please make sure that you sign forms where indicated. If you would like me to read them before we meet, please send them to my office address, otherwise, bring them with you to our first session.

Please also bring payment to the session. I can accept either cash or a check, but not credit or other kinds of debit cards.

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Required Forms To Sign and Bring to Our First Session:.

1.  Agreement and Informed Consent for Treatment
PDF FormThis form gives you detailed and specific information about my office procedures and your agreement for psychotherapy services.  It also includes important information about your privacy and confidentiality.  Please read it carefully, sign it, and keep a copy for yourself.  If you are being seen as a couple, you both should sign this form.  I am happy to answer any questions you have about it when we meet.

2.  Client Information
PDF Form Please fill this out completely as it allows you to share important details and history with me.  If you are coming for couples counseling, each of you should fill out a separate copy of this form.

3. Fee Agreement and Insurance Information
PDF Form Please make sure to fill this out as completely as possible.  If you would like me to help verify your insurance benefits, if any, before we meet, please let me know and I’d be happy to do so.  If you are being seen as a couple, you both should sign this form.

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Forms to Read and Keep for Yourself:

1.  Oregon HIPAA Notice
PDF FormI am required by law to provide you with this Oregon Notice of HIPAA Privacy Practices so that you understand your rights and protections as they relate to the use and disclosure of your identifiable health information.  Signing my Agreement and Informed Consent form acknowledges that you have also read this HIPAA form.

Office Painting

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Forms that May Apply to You:

1.  Couple or Family Confidentiality Statement
PDF FormIf we will be meeting for couples counseling, please read and both of you sign this form and bring it with you.

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2.  Medicare Private Pay Contract
PDF FormIf you are covered under any part of Medicare Part B, you must sign this waiver of benefits and bring it with you, since I am opted-out of Medicare and cannot bill them.  If this applies to you, please also note this on our FEE AGREEMENT.  If you have supplemental insurance, it may or may not cover my services, so you will need to check this carefully, as it can be complicated.

3.  Authorization to use and Disclose Protected Health Information
PDF FormThere may be times when we feel that it would be helpful for me to speak to another person for either past treatment information or to coordinate your care.  Usually we will talk about this in person in the office and you can sign this form at that time.  However, there may be circumstances when you would like to bring this form initially or send it to me if we cannot meet.  If you do fill it out, please read it carefully before you sign it and discuss your intentions with me so we are clear how it would benefit you.

4.  Attendance Agreement for Non-Client Attendees
PDF FormOccasionally during treatment, you may wish to invite another person to participate in a session(s) on your behalf.  This should only be done after discussing this with me.  If we do decide to invite someone, that person needs to be clear that he or she is not a client of mine and you both should sign this form.

503-248-4511  ♦mjw@marciajwoodphd.com♦  5441 SW Macadam Ave. suite 104, Portland, OR 97239
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