Forms

These are forms for new patients to complete prior to their first visit. Please download and print and sign the forms. You can then bring them to your first appointment, or scan and email in advance to: [email protected]

Instructions are included for which forms you need.

Healthy Mind Sacramento-Adult New Patient History (for adult patients 18 and over)

Healthy Mind Sacramento-Child New Patient History (for children under 18, parent should complete)

Healthy Mind Sacramento-HIPAA Notice of Privacy Practices (for all new patients, please read, no need to print anything)

Healthy Mind Sacramento- Acknowledgement of Receipt of Notice of Privacy Practices (for all new patients, signature required)

Healthy Mind Sacramento-New Patient Policies and Agreement Form (for all new patients, signature required)

Optional Forms:

Healthy Mind Sacramento_Credit Card Authorization Form (print and sign and return if you want to keep a credit card on file for billing)

Healthy Mind Sacramento-Consent for Teletherapy Sessions (complete only if you are doing teletherapy)

Healthy Mind Sacramento- Authorization to Disclose Protected Health Information (for permission to share your or your child’s protected health info with someone else; generally Dr. Miller will let you know if needed)