VARIOUS FORMS YOU MAY NEED

 Please read, print and complete these forms to the best of your ability and bring them with you to our first meeting. There are elements of this packet that must be completed before we can even begin working together.  Expect the process to take an average of 20 minutes to complete the entire packet. With this in mind, please do not wait until the last minute.  If you do not have access to a printer, no worries, just come 30 minutes early to your session and grab one from my drawers in my credenza in my waiting room.

 

If client is a minor, please also complete the Child Intake Addendum Form.

If client is a minor in a split custody case, both custodial parties must sign the "Welcome To My Practice" and "Primary Care Physician Consent" sheets.

This grouping of information that I am required to give you includes:
  • A list of actions that constitute unprofessional conduct;

  • A Notice of Mental Health Policies and Practices to Protect the Privacy of Your Health Information (aka HIPAA);

  • My professional qualifications and experiences;

  • The methods for making a consumer inquiry or filing a complaint with the Office of Professional Regulation.

 

Please review as you wish. Then please read, sign and bring in the signature page to our first meeting. Note: This page is not an agreement, simply an acknowledgement that you have been provided with such information.

 

 

Release of Information Form

Required for me to communicate with anyone regarding our work together

This form can seem long and complex but if one simply follows the directions on the form it is easy enough. If you have questions or need help please feel free to simply print the form and bring it with you.  We can fill it out together.

Whatever your reason is for coming to see me, please consider completing these substance abuse screenings and bringing them in with you to our first session. Please note that completion of these screenings (either in or out of session) will be a typical component of doing a required substance abuse screening/evaluation with me. In such cases, completing the screenings ahead of time is recommended as it may expedite the information collection process.

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© 2023 by Marc D. Richter, PLLC. Proudly created by Marc

2 Church St., Suite 3G

Burlington, VT 05401
Marc@MarcRichter.org

Tel: (866) 429-2074
Fax: (802) 540-8199