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James J. De Santis, Ph.D.
138 N. Brand Blvd., Ste. 300, Glendale, CA 91203
112 W. Bennett Ave., Ste. 4, Glendora, CA 91741
(818) 551-1714

The reader is welcome to print any screen from this website for personal use only as
long as author, copyright, and contact information are not removed.

Over the years, we have received many requests from our colleagues for
our office forms. Our forms are now available for purchase.

Who Will Benefit?

This kit may be a both quick and useful system for those who are:

- Newly licensed and wanting to enter practice
- Re-entering private practice after time away
- Shifting from the public sector to private practice
- Successful practitioners wanting to update their materials

The forms in this kit are expressly designed for outpatient mental health
services.

Ethical and Thorough

These forms have been carefully developed during a period of over 10 years
with attention paid to detail. The text has been drafted with the intent
toward achieving the spirit of informed consent, quality of patient care, and
principles of professional ethics. These forms have been heavily field-tested
and are frequently updated based on changes in practice, law, and ethics in
the mental health field. We receive many compliments on the professional
quality of the materials, both wording and format.

Modular Format

The architecture of this kit is modular so that components may be flexibly
assembled based on the needs of the particular situation, whether for
psychotherapy or psychological testing; whether for cash pay, indemnity
insurance, or managed care arrangements; whether for adults or youth.

Customizable

The digitalized version can be custom-edited using most word-processor
software packages. The forms can be modified for use by different
disciplines, including psychologists, clinical social workers, marriage & family
therapists, and professional counselors, or for different state requirements.

List of Forms

Patient Intake

Patient Information
Information About Service
Treatment Agreement
Testing Agreement
Group Therapy Agreement

HIPAA

Notice of Privacy Practices
HIPAA Consent
HIPAA Disclosure Log

Specialized Consents

Release of Information
Coordination of Care with Primary Care Physician
Coordination of Care Between Health Care Providers

Financial Agreements

Financial Agreement
Acceptance of Patient Financial Responsibility
Consent to Bill Third-Party Payor
Third-Party Payor Verification
Indemnity Insurance Agreement
Managed Care Agreement
Parity Insurance Benefits
Lien Contract
Receipt for Services
Patient Fee Ledger

Clinical Forms

Treatment Plan
Symptom Checklist
Adult History Questionnaire
Child History Questionnaire
Medication Record

Practice Management

Professional Executor Instructions

Click here to order your Professional Office Forms Kit.

Office Forms Kit