Francine Grevin, Psy.D., Licensed Clinical Psychologist

Individual Psychotherapy for Children, Adolescents and Adults

 
PLEASE PRINT OUT and sign or complete all relevant forms as noted below*. Completed forms can either be scanned and emailed to: Dr.Grevin@eastbaypsychotherapyservices.com
or, if not possible, mailed to:

Dr. Francine Grevin
1600 S. Main Plaza #225
Walnut Creek, CA 94596
The Office Policy Form, HIPAA Form, Billing Practices and Media Policy Forms are required for ALL clients.
*The appropriate history form(s) (Adult, Child, Teen Questionnaire) should be selected by age. (Adolescents should fill out a Teen Questionnaire and parents of Adolescents should fill out a Child History Form for their teens as well.)

*Treatment of all children and teen under the age of 18 must also include the Consent for Treatment of a Minor form. The latter form requires the signature of ALL parents or legal guardians, as do the Office Policy and HIPAA forms.

*For all teens:  In addition to the the Teen Questionnaire (to be filled out by the teen), a Child History Form should also be completed by a guardian or other appropriate adult.

The Release of Information Form permits  contact between myself and any previous, concurrent or referring clinician(s) as needed and mutually agreed upon.

NOTE: Although you may elect to bring the forms with you to your initial appointment, it is especially helpful for me to have as much of this information as possible in advance of our appointment. This increases the amount of time available to us to discuss your concerns and needs.

CHILD HISTORY

BILLING PRACTICES

TEEN QUESTIONNAIRE

RELEASE/EXCHANGE OF INFORMATION