FORMS

For all patients/clients:

1) Please review the Notice of Privacy Practices (NPP) 

This document is LouCouPsych's notice that provides a clear, user friendly explanation of your rights with respect to their personal health information and the privacy practices of LouCouPsych.

2) Please complete the one-to-two question Acknowledgement of Receipt of NPP

This form simply states that you have received or reviewed and have access to a copy of the NPP as listed above. This is a legal document and will become a part of your medical record.

3) Please complete the Consent to Treatment Form

This form simply states that you are consenting to treatment at LouCouPsych. This is a legal document and will become a part of your medical record.

4) Please complete the Payment Policy

This form states that you understand that LouCouPsych providers are out of network providers, do not participate with any insurance networks, and payment is due at the time of service. A Superbill can provided upon request. This is a legal document and will become part of your medical record.

5) Please complete the Consent to Treatment via Telepsychiatry 

This form states that you are consenting to treatment via telepsychiatry, a method of delivering psychiatric care via an electronic means, such as over an app on your phone, tablet, or video enabled computer. Telepsychiatry is useful if you are unable to come in for face to face appointments due to distance, vacation, or emergencies, for example. This is a legal document and will become a part of your medical record.