Forms

After we have spoken, please complete the 4 forms below (Basic Information Form, Consent To Treat Adult Form and (Consent To Treat Minor Form if you are bringing your child/teenager), HIPAA Form and Telepsychiatry Form. Unless we have spoken about the one other form, the Release of Authorization Information. You don't have to complete the Authorization To Disclose Form, unless you want me to talk to another provider. You can either print the forms out, complete them and bring them into your first session or scan them and email them back to me at markkennedy764@gmail.com. My email is not considered "secure" so just use your initials for your name or child's name. If you have questions or problems, call me at 858-488-5279 - Mark

Optional Forms:

  • Even though I do not participate on panels, I can as a courtesy file your insurance bill electronically for you (as an out-of-network), please fill out the following Insurance form (please read all information very carefully).

  • If you would like to pay for services or charges using a debit card or credit card, I use the program SQUARE to process all payments, it is easy and free for you.

  • If you would like me to speak with a particular friend, family member, or health professional after the intake session, please fill out the first form: Authorization To Use and Disclose Protected Health Information.

All of the pages together on this website are considered a disclosure of my practices and policies.


Client Basic Information with additions MK Dec 2013.pdf
Consent to Treat Adult MK Dec 2013.doc
HIPAA and treatment consent MK Dec 2013.doc
Authorization To Use And Disclose Protected Health Information.docx
Consent to Treat Minor MK Dec 2013.doc
Blank Telepsychiatry release form .pdf