Hello!
You have opened the folder containing questionnaires for new clients. If you have an initial appointment with Dr. Wellborn, it will be important for you to print off the appropriate forms in this folder, complete all sections in each form and bring the completed forms with you to your first meeting with Dr. Wellborn.
In order to make the best use of the first meeting, please make copies of the forms listed below. This may seem like a lot of paperwork. However, answers to these questions will help Dr. Wellborn better understand why you are meeting and to provide him with important background information. Some of the information may also be required to access your insurance benefits. By completing these forms now, you can spend your meeting time with Dr. Wellborn talking about why you came in and what might make things better rather than taking time to fill out forms. The following is a list of the forms to complete and bring with you to your meeting with Dr. Wellborn.
There are 6 forms to print off and bring with you.
1. PSYCHOLOGICAL SERVICES CONSENT FORM
Print off and complete this form. The client (if 16 or older) and their parent or guardian (or the individuals responsible for payment) must initial each section and sign the form on the last page. This form provides important information about your rights and obligations as a client.
2. PSYCHOLOGICAL SERVICES CONSENT FORM FOR PARENT OR LEGAL GUARDIAN
Print off and complete this form if the client is a child or adolescent. This form provides important information about your rights and obligations as a parent or legal guardian.
3. BACKGROUND INFORMATION FORM
Print off and complete either the Child/Adolescent form or the Adult form. Please complete the form that is appropriate for the identified client (the person who will be Dr. Wellborn’s official client). Please complete every section of the questionnaire you select.
4. HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT FORM
Please print and sign the last page of this form. This signature page indicates that you have read and understand your rights as a client under the Health Information Portability and Accountability Act (HIPAA).
5. EMAIL & CELL PHONE CONTACT CONSENT FORM
If you are willing to be contacted through email or by cell phone (including calls and texting), please print this form, provide your email address and then sign in the appropriate places.
6. SOCIAL MEDIA INFORMED CONSENT FORM
Please read and sign Dr. Wellborn’s policy on the use of social media (e.g., texting, Facebook, Twitter, etc.).
PSYCHOLOGICAL ASSESSMENTS OR ACHIEVEMENT TESTS
Please bring copies of any psychological assessments and achievement tests (for children and adolescents) on the identified client.
IF YOU ARE GOING TO TRY TO USE INSURANCE BENEFITS:
Dr. Wellborn is not a provider on any insurance panels. He only accepts out of pocket payments for services. However, some insurance plans will reimburse you for part of these charges. Please review the Insurance page to learn more about this policy. This checklist may be helpful if you contact your insurane provider to ask about any benefits that may be available to you.
There is lots of information on the other pages of the office section of this website about Dr. Wellborn, his background and training, the location of his office, charges and billing, approaches he uses, as well as many things that you may find useful and interesting. If you have any questions or concerns, don’t hesitate to call. See you soon.