Child Psychology Marin
Dr. Julie Maccarin, Ph.D., OT/L
Child Therapy Forms
Below you will find the Intake Information and the Informed Consent for Treatment. Both of these forms need to be downloaded, filled out, and returned to me.
If you are separated or divorced from the parent of your child, please download and complete the Addendum for Divorced or Separated Parents form and return that to me as well. I will need all of these forms from both parents, except under extraordinary circumstances. Pease inform me if there is a problem with this.
The HIPPA form and the the No Surprises Act forms are for your information. Please do not return those to me.
This form provides me with information about
your child and your concerns, which helps me be able to provide the best treatment for your child.
This form provides information and requires your consent for therapy. It also includes information about the policies and fees of Child Psychology Marin. It is recommended that you keep a copy
of this document for your records.
This form provides information about policies and consent regarding parents who are separated or divorced.
This explains the No Surprises Act which provides information about consumer protections. This is for your information. You do not need to return this to me.
This form provides you with information about the privacy and security of your health information. This is for your information. You do not need to return this to me.