Please read and complete the New Client Forms prior to your first session and bring them to your first appointment. The completion of these forms will allow for more appointment time together with you rather than focusing on paperwork. If the new client is under 18, the forms should be completed by the custodial parent or guardian.
- Client Contact Information
- Client Services and Consent Agreement
- Client Intake Form
- Client Background – Not required. Please only complete if you are comfortable with providing this information.
- Releasing Information – Please complete if there is someone with whom you would like BCAD to communicate.
- Request to Restrict Use or Disclosure of Information
- E-Mail Communication Authorization
- Credit Card Authorization
HIPAA and Privacy Forms
If you are currently a Medicare recipient or if you anticipate being eligible for Medicare in the next 2 years, please complete the Medicare Private Contract for your provider. These forms confirm that you are entering into a private contract with your provider and that Medicare will not provide reimbursement for services. Please note, Dr. López currently is unable to see individuals with Medicare coverage.