Forms

Patient Fee and Consent Form

This is a secure form you can complete online and is encrypted.  This is the preferred method, to save trees.  If you would rather print and complete the form and bring it to your first visit, download it here.

AUTHORIZATION TO RELEASE PHI outgoing
There are times when you may want me to release information about you to others.  Because our discussions are confidential (with the exceptions listed in my Privacy Policy – HIPAA) I will need your signed consent to release Protected Health Information (PHI).  Release of information includes both written records and verbal information.

AUTHORIZATION TO RELEASE PHI INCOMING
There are times you may want another healthcare professional to talk to me or otherwise release information to me.  They will want your authorization to release the Protected Health Information (PHI).  This form should be completed and sent to the professional who will be releasing the information.  Only the party releasing the information needs your consent.

Custody Fee and Consent
If I will be conducting a child custody evaluation for you, print, complete and return these forms along with the required retainer fee and the Order of the Court.

Initial Parent Questionnaire
For parties in a custody evaluation,please open this file in your word processor,  complete and return to me.

Collateral Contacts Form
For parties in a custody evaluation, please complete the collateral contact form.

Collateral Consent Form
For parties in a custody evaluation, please send this form  to each collateral to whom you want me to talk and ask them to return it to me.

Reunification Consent and Fee Form
For reunification therapy for estranged parents and children, complete and bring this form to your first visit.  If the other parent is financially obligated, have them complete and return the form, as well.

Special Master Fee and Consent
If you have been Court Ordered to use me as your Special Master, Please read them carefully, complete where indicated, and return them to me with the required retainer fee and Order of the Court.

Parenting Coordination Fee and Consent
If you plan to use me for Parenting Coordination Services, please download these forms, read them, complete where indicated and return with retainer fee and Court Order (if any).

Agreement to Mediate
Divorce Mediation forms can be obtained here.

Court related Fee and Consent
If I am to conduct a court-related evaluation other than a custody/parent-time evaluation, complete this form and return it with retainer and court order (if any).
This would apply to parental fitness evaluations, second opinion reviews of other custody evaluations, etc.

Forensic consult fee consent
Download if you want court related work (such as review of others’ evaluations or testimony) that does not involve a current evaluation by Dr. Wehl.

HIPAA Privacy Policy