SECURE PORTAL

HIPAA Compliant Email Here

If you are using insurance please attach pictures of the front and back of your insurance card, as well as fill out a HIPAA form for your insurance company.

This portal is also the best way to send Deirdre a confidential email.

 

FORMS

Electronically Sign the Forms Below

If you have an intake with Deirdre please fill out and sign the forms below before your first appointment. These forms will be sent directly to Deirdre through the secure portal.

EMERGENCY RELEASE FORM

(This form must be filled out)

This form should be downloaded and filled out for each person whom you want me to be able to share and receive information from. Please download this form if you have an intake with me and fill this out for your any person who may be paying for your therapy, any doctors you may want me to contact, if you are changing your emergency contact person, and fill it out for your health insurance/EAP you are utilizing for therapy. This form will need to be downloaded and filled out for each individual you want a release for.

This form was included in the Intake Packet for your emergency contact. Download extra for all other people or organizations you want me to be able to speak to.

DOWNLOADABLE QUESTIONNAIRES

These can be downloaded, printed, filled out, and brought into the first session OR marked electronically and submitted through the secure portal above.





These questionnaires will help Deirdre gain a better understanding of how to help

INTAKE PACKET

This packet must be filled out before the initial assessment

This packet will need to be filled out in its entirety. Please read it over and, if you agree, sign each page that requires it. 

In this packet is an extra HIPAA Release form for any person or organization you may want me to have contact with. Examples of these are insurance companies I need to contact, doctors you may want me to correspond with, or a family member who may be helping you pay.


You may leave the HIPAA form in this packet blank if you do not want any more releases of information.

More HIPAA forms are available upon request.

DOWNLOADABLE INTAKE PACKET

If you prefer to download and fill out by hand and physically bring this into the office - you may use this form. This is instead of electronically signing.





This packet is the exact same as the packet to the left. (Only one needs to be filled out). 

HIPAA RELEASE FORM

(This form can be filled out for person or organizations you want Deirdre to be able to communicate with.

This form should be downloaded and filled out for each person whom you want me to be able to share and receive information from.  

This form was included in the Intake Packet for your emergency contact. Download extra for all other people or organizations you want me to be able to speak to.

HIPAA RELEASE FORM

(This form can be filled out for person or organizations you want Deirdre to be able to communicate with).



This form is exactly the same as the one to the left. This form has the capability of electronic signature. It will be automatically sent to Deirdre when signed and submitted.

POLICY AND PRICE UPDATE 7/2022

All current clients please fill this form out and sign electronically if you agree to the new policy changes.

HEADWAY AGREEMENT

All current clients please fill this form out and sign electronically if you agree to the new policy changes.