Thank you for requesting your appointment with Dr. Bettina, I look forward to meeting with you.
Prior to your appointment, please print and complete the required forms which fit your situation and email them to firstname.lastname@example.org *.
If you have questions please email (email@example.com) or call our office at 480.285.7011
Forms for Therapy Appointments
- New Patient Forms
- Agreement for Couples Therapy
- Agreement for Family Therapy
- Agreement for Additional Participants (if you would like someone to join your session)
- Notice of Privacy Practices (for informational purposes)
- Medicare Opt Out Private Contract (only for those covered by Medicare)
- Electronic Communication Policy (for informational purposes)
- Authorization to Release Records (if you would like me to communicate with someone on your behalf)
- Telepsychology Informed Consent
Forms for Life Coaching Appointments
* Pursuant to the No Surprises Act which took effect January 1, 2022, you have the right to receive a “Good Faith Estimate” for the total expected cost of any non-emergency healthcare services, including psychotherapy services, before they begin. Although it is not possible to predict the number of sessions you will need before services are provided, you can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, or how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises.