Appendix II: Sample Forms

We offer the following forms as examples of the kinds of forms you might find useful in your independent practice. The forms include one to use in tracking referrals; an “Authorization to Release Information” to waive confidentiality; a “Patient-Therapist Agreement” describing fee policies and procedures; an “Application for Payment Plan” for those clients who cannot or do not want to pay at each session; and a combined patient information—fee agreement form that clients fill out before their first session. As we have suggested throughout this book, you should tailor the forms to your particular practice and modify or add to them as your practice grows and changes.



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