Child Psychology Marin
Dr. Julie Maccarin, Ph.D., OT/L
Child Therapy Forms
Below you will find, the Informed Consent for Treatment, the Informed Consent for In-Person Therapy, the Informed Consent for Telehealth, and the No Surprises Act forms and return them 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. The HIPPA form is yours to keep and you do not need to return that 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 consent for in-person therapy.
This form provides information about policies and consent regarding parents who are separated or divorced.
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 and consent for telehealth.
Health Insurance Portability and Accountability Act
This form provides you with information about the privacy and security of your health information
This explains the No Surprises Act which provides information about consumer protections