Notices and Forms
Jonina D. Bolton, Ph.D.
Licensed Psychologist
                        Application for Clinical Services

       Purpose of these forms: Everyone is required to fill out these forms, prior the
      first appointment. It includes the Application, Services Agreement, Financial   
      Policy and Agreement and the HIPAA Notice of Privacy Practices. The
      Communication Agreement below will also be required.
      Please print any form(s) you may need, fill them out completely, and
    then bring them with you to your appointment. All forms require an original
    signature. If you have any questions, feel free to call Dr. Bolton at 772-234-7100
    or discuss your questions in person at your scheduled appointment. To access
    the form(s), click on the name of the form(s) listed below and it will open in
    another window. Please note that you need Adobe to open these files. To
    return to this website after viewing or printing a form, use the back button in
    your browser.

Authorization to Use or Disclose Protected Health Information
                               (Also known as a Release of Information Form)

    Purpose of this form: Because your mental health records are considered
    private and confidential, this form, or one similar to it, is required whenever
    information about you is being disclosed or exchanged. In most circumstances,
    an exchange of information pertaining to any prior or current treatment is done
    so at your voluntary request. This form is required in order for Dr. Bolton to
    obtain information from, or provide information to, another individual, program
    or facility, such as a prior therapist or counselor, medical doctor, psychiatrist,
    or hospital, regardless of the purpose of the verbal or written exchange.
                          Revised Financial Agreement
                                      (For Changes Only)

    Purpose of this form: This form is for established patients only. Any changes
    to your initial financial agreement established with Dr. Bolton will require a new
    form to be completed. Reasons for changing an initial financial agreement
    include: switching from cash-pay to utilizing insurance benefits or vice versa,
    as well as any changes to your insurance coverage or benefits that result in
    a different co-payment. If you are a new patient, you do not need to print this
    form because an initial financial agreement form is included in the Application
    for Clinical Services above.
    Child Intake Form - In addition to the Application above
              (Initial Appointment Only for Patients under Age 18)

    Purpose of this form: This form contains additional information gathered for
    all patients under the age of 18. This form is in addition to the Application for
    Clinical Services; both forms are required for minors.
                          Communication Agreement

    Purpose of these forms: These forms include how you want Dr. Bolton to
    communicate with you, an explanation of the current telephone system and
    information on unencrypted communications. All patients must complete these
    forms.

                                       HIPAA Notice of Privacy Practices
                                                    (Included in the Application forms)

    Purpose of this notice: This notice describes how medical information about
    you may be used and/or disclosed, patient rights and how you can get access
    to this information. Please review it carefully and completely and then sign the
    acknowledgement page confirming that you have received a copy of this Notice.