Online Patient Registration Forms

​Please fill out and submit all patient registration forms at least 2 days prior to your initial evaluation. These forms can be completed online.

Patient Registration Form

Patient Consent Form

Patient Authorization Form

Card Authorization Form

Medicare Opt-Out Contract

---

Downloadable Forms

The following forms are provided for your convenience. Please click on a form below to download the PDF file to complete or print a copy.
​

• Patient Registration Form
• Release of Medical Information Form
• HIPAA Form
• Privacy Practices Awareness Form
• Schedule of Fees
• Card Authorization Form

Have a Question?

Contact the office manager, Rikki, by calling 434-244-3771 or send an email.

---

Areas of Practice

• Anxiety Issues
• Mood Issues
• Difficult Relationship Issues
• Significant Life Transitions
• Life Direction, Values, and Meaning