LEIGH W. JEROME, PH.D.
  • Home
  • About Me
  • Specialties
    • Anxiety & Existential Angst
    • Artists & Creatives
    • Depression & Grief
    • Gender Dimensions
    • Highly Sensitive People
    • Leadership & Motivation
    • Long COVID & ME/CFS
    • Post-Traumatic Growth
    • Relationships
    • Self-Esteem
    • Sexual Abuse
    • Stress
    • Transformation
    • Women & Women’s Health
  • Forms
    • Contact Us
    • Psychology Intake Form
    • Conditions of Treatment
    • HIPPA Authorization
    • HIPPA Notice
Schedule Appointment

 

Please complete the following forms prior to your first visit.

Psychology Intake Form

  Psychology Intake Form

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HIPPA Authorization

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA  

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HIPPA Notice

HIPAA Notice Form Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS …

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Conditions of Treatment

CONDITIONS OF TREATMENT (Please read and Sign)   Confidentiality – All information discussed during sessions is confidential and will not be divulged to anyone without expressed written consent. Limits of Confidentiality – The only …

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