At Therapy Changes, we put your comfort at the forefront of all that we do. We operate smooth office processes so that you can focus on what matters most: your care.
New Client Forms
For your convenience, all required forms will be accessible through your client portal upon scheduling. Individually signed forms are needed for each participant. If you are a part of a couple or family seeking therapy together, you will each need to complete your own forms.
Consent to
Treatment
The success of therapy depends upon a high degree of trust between you and your therapist. The required consent to treatment provides an understanding of therapy to fully inform you about what to expect from therapy and from your therapist. Before a therapist can begin sessions with you or your child, the Consent to Treatment form must be signed. If the client is a minor, ALL legal guardians must sign.
Notice of Privacy Practices
The HIPAA Notice of Privacy
Practices is required by the government and provides information regarding use and disclosure of your medical information.
- Notice of Privacy Practices
Release of Information
If you would like your therapist to speak to another therapist, medical doctor, family member or another individual regarding your care, please complete
and return the following form:
- Authorization to Release Information
|
|
|
Elliot J Gursky, MD
Child, Adolescent and Family Psychiatry
|
|
|
|
|
| Home
|
| Services Provided
|
| Common Questions
|
| Appointment Request
|
| Helpful Forms
|
| Contact Me
|
| Privacy & Policy
|
| Hot Topics!
|
|
|
| Elliot J Gursky, MD 609-924-6294 92 Nassau Street Princeton, NJ 08542 US
|
|
|
|
|
|
|
|
| If you're a new patient, please complete the following forms and bring them to your first session. - New Patient Questionnaire
- Consent for Treatment
- HIPAA Authorization Form
- PQ-9 Form
- ADHD-self form page 1 of 2
- ADHS-self form page 2 of 2
- ADHD-parent form page 1 of 2
-
ADHD-parent form page 2 of 2
If you would like me to coordinate care with another provider (for example, primary care physician, etc.), complete this form to authorize release of your psychiatric information: -
Release of Medical Records Form
Note: To download Adobe Acrobat Reader for free, click here.
|
|
|
|
Schedule Appointment Start your new path in life and be the change today!
| Helpful Forms Click here to view and print forms for your appointment
|
|
|
|
|
|
|
What form is used to allow the release of their medical records?
The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. The release also allows the added option for healthcare providers to share information.
What is a release authorization form?
This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.
What should be included in a authorization for release of information?
The core elements of a valid authorization include: A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.
What is a release of information in counseling?
A signed Release of Information must be obtained from an individual or an individual's legal representative prior to using or sharing the individual's confidential information for the provision of services, treatment, payment, or health care operations, unless otherwise permitted or required by law.