Forms

Before your initial appointment at The Mariposa Center, please complete the following forms. If you have any questions about the paperwork, please feel free to contact us.

Client Form Packet – All Forms
This document contains all of the forms required for a client.

IMPORTANT NOTE: A child/infant’s legal guardian must sign all paperwork even if the child does not live with that person. If the child/infant is in a joint custody situation or decision-making is shared among two caregivers, both caregivers must sign all paperwork and consent to the therapy.

If you have already completed the initial form packet (above) and only need to update one part of your information, you can download the individual forms below:

Disclosure Statement
By signing this form you are giving your consent to work with a therapist at The Mariposa Center. It discusses confidentiality and your rights as a client participating in psychotherapy. Please feel free to print out an extra copy for your own records as there may be information you want to refer back to in the future.

Release of Information
The release of information (ROI) is the legal form that gives your therapist permission to discuss the therapy with parties of your choosing. If you would like your therapist to be able to share information with schools, doctors, other kinds of therapists, or other family members, then a form for each organization/person must be completed. If an organization such as an insurance company or early intervention program is paying for the therapy, then you must sign an ROI, as it gives The Mariposa Center permission to bill for services.

Consent for Communication of Protected Health Information by Unsecure Transmissions
This consent form is for the communication of Protected Health Information (“PHI”) that the therapists at The Mariposa Center may transmit without the written authorization of the client as described in the Uses and Disclosure section of its Notice of Privacy Policies.

Assignment of Benefits
This form authorizes your insurance company to issue payment directly to the therapists at The Mariposa Center.

Client Contact Information
This provides essential contact information to your therapist.

Financial Information and The Mariposa Center Policies
This form reviews financial and The Mariposa Center policies in detail. Please initial where indicated throughout the form and sign when complete.

Credit Card Authorization
This form grants The Mariposa Center permission to charge for therapy sessions, co-pays, and missed appointments.

Notice of Privacy Practices
This is our copy of the federal Health Insurance Portability and Accountability Act (HIPAA) form that all health care providers are required to give to their clients. It goes over your rights to privacy as a client working with The Mariposa Center. Feel free to print an extra copy for your records.