| Forms |
| Jonina D. Bolton, Ph.D. Licensed Psychologist |
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| Application for Clinical Services (Initial Appointment Only) Purpose of this form: Everyone is required to fill out these forms, prior to the first appointment. |
arrival. 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 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 Form (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 application above (Initial Appointment Only for Patients under Age 18) Purpose of this form: This form contains additional information gathered for all patients under age 18. This form is in addition to the Application for Clinical Services; both forms are required for minors. |