In preparation for the first visit with Dr. Julie Lopez, LICSW, please complete the following forms and bring them to the session:
Each of our Clinical Associates is a licensed practitioner. As required by licensure, treatment under a licensed practitioner is confidential. This form explains limitations to that confidentiality required by licensure. It also outlines the collaborative nature of the therapeutic relationship and co-responsibility for treatment outcomes.
Julie Financial Form
This form outlines The Viva Center’s financial policies. Here at Viva, we offer special accommodations to assist with cash flow and to simplify payments. As a professional courtesy, clients opting to pay with a credit card are not billed until the end of the month, although fees are technically due at the time of service. This allows time for insurance to send reimbursement closer to the time of payment.
This form serves 2 purposes: It helps to capture the baseline experience when beginning treatment, allowing for an opportunity to take stock of current status. It also helps the clinician gather important background information without taking extra time in the first session. The first page of this form is required, and the others are supplemental. It is fine to exercise the decision to leave out any areas of the form. Please keep in mind any areas elected not to be disclosed at this time may be relevant to treatment outcomes.
Credit Card Authorization Form
This form is only required if electing to use a credit card to pay for services. Conveniently, this form only needs to be filled out once and is stored securely. Payment with cash or checks is also accepted.