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Please click on forms to download and print.


Fax to 855-302-4621 or scan and email back to
office@amysheinbergphd.com at your convenience, but before your appointment date. Thank you.

 

New Patient Packet for Minors (Click here to download)

(The Patient Information form, Intake Questionnaire, Notice of Privacy Practice/HIPAA form, Credit Card Information and Consent for Email/Text Communication must be completed. If your child is an adolescent, please fill out the Adolescent Informed Consent form. If you wish to have me communicate with another provider or facility, please fill out the Release of Information form for each provider or facility. If we may at some point communicate via video conferencing (e.g., Skype or FaceTime), you must fill out the Teletherapy Service Agreement and Informed Consent form, and Agreement Concerning Psychologist's Testimony and Records. If this case involves any legal matters, please inform Dr. Amy Sheinberg as soon as possible.)

New Patient Packet for Adults (Click here to download)

(The Patient Information form, Intake Questionnaire, Notice of Privacy Practice/HIPAA form, Credit Card Information and Consent for Email/Text Communication must be completed. If you wish to have me communicate with another provider or facility, please fill out the Release of Information form for each provider or facility. If we may at some point communicate via video conferencing (e.g., Skype or FaceTime), you must fill out the Teletherapy Service Agreement and Informed Consent form.

Individual Forms

Patient Information

Intake Questionnaire

Notice of Privacy Practice/HIPAA

Consent For Email/Text Communication

Credit Card Information

Release of Information

Adolescent Informed Consent

Teletherapy Services Agreement
and Informed Consent

Agreement Concerning Psychologist's
Testimony and Records (Adult)

Agreement Concerning Psychologist's
Testimony and Records (Minor)

 

If you are unable to open these documents, please download

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Office Number
214 361 0660 voice

8333 Douglas Ave., Suite 1240
Dallas, TX 75225

Copyright © 2017 Amy Sheinberg, Ph.D. All rights reserved.
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