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.

Telepsychology Consent Form

AUTHORIZATION TO RELEASE PHI outgoing
This is a secure form you can complete online.  If you would rather print the paper form and scan it and email or mail it to me, download it here.

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.

Co-Parenting Therapy 

Please complete this online consent form for Co-parenting therapy.  If you prefer to send a paper form, download it 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