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.

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

Emily Pimpinella, Psy.D.