Dr. David Koehn
psychologist

Registration Forms

You will need Acrobat to open & print a PDF PAGE- FREE download - click here

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HIPPA / FINANCIAL RESPONSIBILITY

Policies regarding Protected Health Information (PHI)
Financial Responsibility - Click here (PDF)
HIPPA Consent - Click here (PDF)
HIPPA Attestation - Click here (PDF)
Informed Consent - Click here (PDF)

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RELEASE OF RECORDS

Policies regarding cancellations, billing, & payment (including insurance, if applicable).
Insurance Consent - Click here (PDF)
Insurance Claims and Payment Information Sheet- Click here (PDF)
Information Verification - Click here (PDF)
RELEASE OF RECORDS - Click here (PDF)
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CHILD / ADOLESCENT

Consent for psychological services/mental health treatment for the CHILD
CHILD / ADOLESCENT INFORMATION (Age 15 and Younger) - Click here (PDF)
iNFORMED CONSENT - Click here (PDF)

CHILD comprehensive background history. - Click here (PDF)

ADOLESCENT comprehensive background history. - Click here (PDF)
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ADULT

Your contact information and basic demographics.
ADULT CLIENT INFORMATION - Click here (PDF)
ADULT BACKGROUND HISTORY - Click here (PDF)