Sharon Cummins' Documents

For All Clients

Declaration of Practices and Procedures – This document describes the nature, parameters, and work of the therapy relationship. Please print and sign the acknowledgement on the last page.

Privacy Policy – This document describes our adherence to the Health Information Portability and Accountability Act (HIPAA). Please print and sign the acknowledgement on the last page.

Fee Payment Policy – This document describes expectations regarding payment for services. Please print and sign the acknowledgement on the last page.

Adult Information Form – Each adult beginning individual or couples’ therapy should complete this form as completely as possible.

Child/Adolescent Information Form – This form should be completed by guardians of all children under the age of 18.

Child/Adolescent Psychiatry Screen – This symptom checklist is used by permission in conjunction with the Child/Adolescent Information Form should be completed by guardians of all children under the age of 18. It allows us a head start in getting to know your child and any behaviors of concern.

For Parent Coordination Clients

Parent Coordination Agreement – Each parent beginning the parent coordination process must attend their individual evaluation having reviewed and prepared to discuss this agreement.

Parent Coordination Fee Summary – This document describes the relevant fees for Parent Coordination services and must be reviewed and signed prior to beginning the process.

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