Child Psychology Marin
Dr. Julie Maccarin, Ph.D., OT/L
Child Therapy Forms
Below you will find links to three forms. Please download and complete the Intake Information form and the Informed Consent for Treatment form
and bring them with you to your first appointment. The HIPPA form is yours to keep.
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.
Informed Consent for Treatment
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.
FEES are listed in the form: Informed Consent for Child Therapy. Due to the pandemic which is causing hardship for so many, I am offering a few spots for clients who need reduced fees. Please discuss this with me if you feel your family qualifies for reduced fees.
This form provides information
and consent for using telehealth.
Health Insurance Portability and Accountability Act
This form provides you with information about the privacy and security of your health information