Intake Forms

If we have agreed that we can arrange an initial appointment, please download and complete the following (.pdf file) forms and use the link below to upload the completed and signed forms (you can complete and sign them electronically with Adobe Acrobat Reader):

https://hushforms.com/steveblankman-secure-file-transfer

(You can also use the above link to securely upload other documents to me, including the assessment and therapy forms and handouts at the bottom of this page.)

  Also include the Telepsychology Consent Form and the relevant insurance forms below:

• Client Intake Form, page 1
• Client Intake Form, page 2
• Psychologist-Client Services Agreement
• HIPAA Privacy Notice

To participate in Telehealth sessions (online video), please download, read and sign this form and include it with the above intake forms:

• Telepsychology Consent Form

To optimize your televisits read the following:

• Technical Tips for Televisits

If you wish to use health insurance (other than Medicare) to help pay for my services, please download, complete and sign the following form.  Use this form also for your Medicare supplemental insurance if you have it.  It would be helpful if you can photocopy both sides of your insurance card(s).

• Authorization for Insurance Benefits

If you are a Medicare beneficiary and wish to use Medicare to help pay for my services, please download, complete and sign the following form.  If you can, please photocopy your Medicare card on the bottom of the form.  Write your Medicare ID number above where it says "HIC Number," and sign and date in the middle of the form:

• Medicare Authorization form

If you would like me to provide information to another person or entity (for example, your psychiatrist, primary care physician, etc.), please download, print and complete this form to authorize me to release your information:

• Authorization to Disclose Information Form

If you would like another person or entity to release confidential information to me, please download, print and complete the following form: 

• Request/Authorization to Release Confidential Information

You can use the following link to securely upload documents to me, including the forms below:

https://hushforms.com/steveblankman-secure-file-transfer

Assessment Forms

• Patient Health Questionnaire (PHQ-9)

Therapy Forms and Handouts

• OCD self-monitoring form, page 1
• OCD self-monitoring form, page 2
• Exposure recording form
• Thought record form
• Questions to evaluate unhelpful thoughts
• Relaxation recording form
• Helpful and unhelpful thinking (rumination)
• Worry Diary

Note: To download Adobe Acrobat Reader for free, click here.