Paperwork/Forms

Here are the forms that need to be filled out prior to an intake appointment in anticipation of a Telehealth video session. You may download them at your convenience and send back to the office.

 

Please read each form carefully and sign accordingly. You may not return these forms through this website via email, as email is not HIPAA compliant. 

To return the forms, please either mail or fax them to our office.

 

If sending by mail, please send to this address:

SRI Psychological Services, P.C.

93 York Road, Suite 203

Jenkintown, PA 19046

 

If sending by fax, please fax to (215) 885-3090.

 

Thank you for your continued understanding during this transitory time. If you have any questions or concerns, please do not hesitate to contact the main office at (215) 885-3337 or contact the therapist directly with whom you are scheduled to see for an intake appointment. 

Click PDF to download Intake Paperwork

Click PDF to download Credit Card Authorization Form

Click PDF to download Cancellation/ No Show agreement form

Click PDF to download Notice of Privacy Policy form

Click PDF to download SRI Consent to TeleHealth

Click PDF to download Notice of Release of Information form

Jenkintown Office:

Jenkintown Commons

93 Old York Rd

Suite 203

Jenkintown, PA 19046

215-885-3337

SRI

Psychological Services, P.C.

Philadelphia Office:

Revere Commons

2824 Cottman Ave

Suite 19

Philadelphia, PA  19149

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