patient formsPlease thoroughly review and complete the first three forms below in preparation for your first session.

NOTE: If your child/adolescent is the patient, it is very important both parents complete forms and attend the first session.

Patient Information

This form provides Dr. Scheckner with pertinent patient background information. If you are the patient, please fill out with yourself in mind. If your child is the patient, please complete with the child in mind. Complete this form with as much detail as possible to appropriately treat your family.
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Policies and Procedures

This form provides you with the policies and practices regarding the privacy of your health information. Please thoroughly review and sign/date at the end.
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Outpatient Services

This form reviews the following important information: appointments, professional fees, billing and payments, telephone calls, confidentiality, patient rights, minors/family, and office space. Please thoroughly review and sign/date at the end.
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Optional

Authorization for Release

This form is for times when Dr. Scheckner may need your permission to speak with other professionals, such as your child’s pediatrician, psychiatrist, teacher, or any other person in order to collaborate and best treat your family.
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Billing Record

This form serves as documentation of your payment each session. Please print a copy for your own end-of-year tax purposes.
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Service Receipt

Please use this form for any documentation such as insurance reimbursement; please note, you must keep track of dates of services rendered as Dr. Scheckner will charge for time rendered in looking up documentation at the end of the year.
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Communication Support

This form explains communication guidelines when you need support in between sessions. Review these options very carefully so you know what to do depending upon the severity of distress. This is an extremely important part of the therapeutic process as progress takes time.
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