Patient Forms

If you have arranged an appointment with Dr. Cuneo, please complete the forms listed below before your first visit.  The information you provide will make our time together more productive.  If you have any questions about these forms or are uncertain or uncomfortable about how to complete them, we can discuss the information in person at our first session.

Please print and complete the forms in either the Child or Adult Forms section depending on the age of the patient. Child forms are for children under 18 years of age. Please bring the completed forms with you to your first session.

Patient Forms for Children:

 

Client Information

Notice of Privacy

Patient Agreement Form

Assignment of Benefits

Consent for Telepsychology Services

Email Consent Form

COVID In Person Consent Form

Patient Forms for Adults:

 

Client Information

Notice of Privacy

Patient Agreement Form

Assignment of Benefits

Consent for Telepsychology Services

Email Consent Form

COVID In Person Consent Form