Forms + Notice of Privacy Practices

All my forms (such as Records Requests and Releases of Information) can be

accessed and electronically signed through the Client Portal (link below).

Just let me know what one you need and I will upload it for you.

If you don't currently have access to the portal and would like to, please let

me know and I can grant you access.

Client Portal

Below are PDF versions of the most common forms. If you are sending me a form, please call me

and give me a heads up so I know to expect it, and also to navigate possible instances where

I could be out of the office for a time period so we can discuss options.

Authorization for the Release of Confidential Information

(Use this form if you want me to share your information and/or

records with someone else.)

Records Request

(Use this form if you are requesting your own records for yourself)

*Please note that the in-person pick-up option is not currently

available due to Covid-19.

Notice of Privacy Practices

Rights and Protections Against Surprise

Medical Bills for Uninsured and Out-of-Network Clients

Rights for a "Good Faith Estimate" for

Uninsured or Out-of-Network Clients

Emily Pimpinella, Psy.D.