Client Forms

Client Forms and Documents

For ALL Clients (New and Existing): Depending on how long ago you received services from Dr. Melissa Artnak, you may also need to update information which you previously provided as a New Client.

  • Notice of Privacy Practices ~ I am required by law to provide you with a copy of the HIPAA Notice of Privacy Policies document so you can understand your rights and protections related to the use and disclosure of your identifiable health care information. When you arrive at the office we will provide you with a copy. A copy is also available on my website for your convenience.
  • Acknowledgement of Receipt of the Notice of Privacy Practices ~ The law requires me (your doctor) to ask for written proof that you received the Notice of Privacy Practices, in what is called an “acknowledgement of receipt.” This form will be provided to you when you visit our office prior to your appointment.
  • Health Information Disclosure Form ~ This form is needed only if you want me to share/release any health information about you (the client) with anyone, such as: your physician, a school counselor, a teacher, or someone else involved with you or your child / family member.

For NEW Clients: As a new client, you will need to fill out and sign some forms in order to receive services from Dr. Melissa Artnak. Prior to your first appointment, please print and complete the following New Client forms listed below. Please bring them with you to your appointment. If you are unable to print or complete the forms, please contact the office and we will assist you.

These forms can also be completed at your first appointment; however, in that case please arrive 15 minutes early to ensure adequate time to complete them. Otherwise, we will have to use part of your session time in order for you to fill out the forms.

  • Psychological Services Contract ~ This form must be completed prior to our first meeting and it simply states that you agree to services provided by Dr. Artnak for either yourself or a family member. This form also discusses office policies with respect to payment for services, including handling of insurance, canceled or missed appointments, how payments can be made, and processes for unpaid accounts. Dr. Artnak cannot meet with a minor without this consent being signed by the parent(s)/legal guardian(s).
  • Patient Registration Form ~ This form asks you to record information about the patient (client), reasons for the appointment, and insurance information (if applicable). This will also help you share important details with me while allowing our first meeting to concentrate on the client's needs.