Please complete all forms and email them prior to your first appointment to: info@drleahsamler.com. All email communication is HIPAA compliant and encrypted.
Intake Information (1) (docx)
DownloadInformed Consent for Therapy Services (docx)
DownloadConsent for Release of Information (docx)
DownloadInsurance Information (docx)
DownloadCancellation Policy (doc)
DownloadContinuity of Care Fees (docx)
DownloadHIPPA ROI (docx)
DownloadNotice of Privacy Policy (docx)
DownloadCredit Card Authorization Form (docx)
Download