Forms

Please download, print and review the following two documents “Client Intake Survey” and “Consent for Treatment and Limits of Liability”, and bring it with you to your first session with Dr. Lehenbauer-Baum. Although these documents are long and sometimes complex, it is very important that you understand them!

If you do not have any opportunity to print these documents, Dr. Lehenbauer-Baum can provide you with copies as well!

1.) Client Intake Form (Adolescents and Adults)

Please download, print and complete this survey and bring it with you to our first session. You will also find a copy in the waiting room area. Feel free to download the form here – Client_intake_form_11.06.2018

2.) Consent for Treatment and Limits of Liability and “Notice of Privacy Practices”:

This document discusses the nature of psychological services provided, confidentiality and limits of confidentiality, the payment and billing methods, appointment and cancellation policies, and your rights as a client. It also includes the “Notice of Privacy Practices”. The Notice of Privacy Practices is a document that provides information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. It also provides information about how Dr. Mario Lehenbauer-Baum conducts himself on the Internet and his social media rules.

You can download a copy here – Adult_informed_consent_and_HIPAA_form_11.05.2018