Patricia Wilkins-Vacca, LCSW, PC
845-527-9456
  • Home
  • About
  • Hours
  • Contact
  • Treatment
  • Forms
  • Services
  • Insurance
  • Through the Ages
  • Walk and Talk therapy

Please print and fill out the following forms and bring to your first session. If treatment is for an individual over 18 and not living at home, you do not need to fill out the family questionnaire form. 
Additional items to bring to first session; name and address of primary care physician, payment. 



demographic_information.doc
File Size: 26 kb
File Type: doc
Download File

consent_to_treat.docx
File Size: 15 kb
File Type: docx
Download File

fee_for_court_appearance.docx
File Size: 12 kb
File Type: docx
Download File

medication_list.doc
File Size: 40 kb
File Type: doc
Download File

family_questionnaire.doc
File Size: 45 kb
File Type: doc
Download File

telemental_health_consent_form.docx
File Size: 13 kb
File Type: docx
Download File

hicf.pdf
File Size: 26 kb
File Type: pdf
Download File

walk_and_talk_consent_form.docx
File Size: 18 kb
File Type: docx
Download File

pcp_authorization.docx
File Size: 15 kb
File Type: docx
Download File

hippa_1.docx
File Size: 20 kb
File Type: docx
Download File

policy_statement_updated__dec_2021.docx
File Size: 23 kb
File Type: docx
Download File

fee_agreement_2022.docx
File Size: 18 kb
File Type: docx
Download File

gfe_notice.pdf.docx
File Size: 15 kb
File Type: docx
Download File

Powered by Create your own unique website with customizable templates.