Forms

Below are the forms that you will need to fill out before arriving for your first session. Please download forms as PDFs, sign and email back to me as attachments to karinconnellyphd@gmail.com. Please let me know if you’d prefer that I mail these forms to you.

Assignment of Benefits

HIPAA – New York Notice Form

Psychotherapy Consent

Intake Form

Informed consent for Telepsychology

 

 

INSURANCE:  Dr. Connelly is an in-network provider with several NYS insurance companies (please check directly with your particular plan). All patients not using insurance are encouraged to inquire about a “good faith estimate” of the cost of services, before commencing treatment. 

FOR ADDITIONAL LOCAL RESOURCEShttp://www.hvpa.org/index.asp