Forms

New clients, please complete the following forms and bring them to your first appointment (intake session).

• EPS CLIENT CONTRACT/PROCEDURES STATEMENT
• EPS NOTICE OF PRIVACY POLICIES.
• EPS ELECTRONIC COMMUNICATION CONSENT

Dr. Mary A. Ellis is an Carefirst Blue Cross/Blue Shield insurance provider. Please complete following forms should you wish to receive coverage under this plan.

• EPS INSURANCE FORM

To coordinate treatment with another clinician/physician and/or consent to discuss clinical issues with those in position to clarify same (such as teachers and parents/guardian, if you are older than eighteen), please complete following form.

• EPS AUTHORIZATION FOR RELEASE OF INFORMATION

Kindly arrive twenty minutes early to complete requisite documentation not otherwise received as attachment with clinical intake appointment email.

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