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Forms

Before your initial appointment:

Consent Form please print, sign and bring with you.

HIPPA Form please read and sign at end of consent form to acknowledge.

Intake Form please print, sign and bring with you.

Forms as needed:

Release if Information Form please fill out and bring with you if you have other parties with whom you wish me to communicate to benefit your treatment (e.g. previous therapist, psychiatrist or other physician)

Credit Card permission form please fill out and bring with you if you wish me to keep your credit card information on file.

Medicare Patient Form

Telehealth Policies/Consent

Please be aware that as of May 1, 2009, all new clients must have proof of identity - for example a government issued ID card or license. If your current address is not the same as your ID address or credit card billing address, please also supply proof of address, such as a lease or utility bill. This policy is due to FTC rules and regulations regarding protecting people against identity theft.


If you began treatment with Dr. Hopper before January 1, 2013, please contact her directly if you need copies of the original forms.