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Forms & Notices

Waves

We know figuring our which forms you need to complete can be confusing. Here's an overview to help make it feel less overwhelming:

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New Patient
Registration Forms

Please complete this mandatory questionnaire if you're interested in receiving services at Psychiatric Services of Suffield. Your answers on this questionnaire will help us ensure that Christine Doucette, PMHNP-BC can offer the level of care and expertise that is right for you and your mental health needs.

 

Submission of this questionnaire does not guarantee a therapeutic relationship between the patient and Christine Doucette, PMHNP-BC.

 

Patients/Parents/Legal Guardians should expect a response to this form submission within 72 business hours.

Parents or legal guardians must complete this registration packet on behalf of all patients ages 17 years or younger prior to scheduling an intake appointment.

All patients ages 18 years and up must complete this registration packet on their own behalf prior to scheduling an intake appointment.

All patients/parents/legal guardians must complete this form in addition to the registration packet prior to scheduling an intake appointment. 

Established patients are required to sign this form upon request any time there have been major practice policy updates but a patient is not yet required to complete an updated comprehensive registration packet.

General Forms

Please complete this form to authorize our practice to send medical records, receive medical records, or communicate with others regarding your care in our office.

When parents or legal guardians of minor patients are separated or divorced and share joint legal custody of the minor patient(s), both parents/legal guardians must consent to treatment in writing.

This form is included in the Child & Adolescent Registration Packet.

All clinical services rendered at Psychiatric Services of Suffield are currently offered via telehealth appointments. All patients in the practice must provide informed consent for telehealth services.

This form is included in both the Child & Adolescent Registration Packet and the Adult Registration Packet. 

Notices

In accordance with HIPAA legislation, this Notice explains how your information is used in our office, how we protect your confidentiality, and what your rights are with regard to your protected health information. 

This Notice provides information regarding your rights and protections against surprise medical bills, per the No Surprises Act.

This Notice provides information regarding your right to receive a Good Faith Estimate for billable services rendered out-of-network or to uninsured patients, per the No Surprises Act. 

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