Acknowledged receipt of HIPAA policies
We at Clinical Associates of Tidewater want to make things as convenient as possible for you. On this page you will find a variety of forms that we encourage you to download and complete prior to your first appointment. Please bring these completed forms with you. The secretaries will give them to your therapist in preparation for your session.
Acknowledge of Receipt of “Notice of Clinical Associates of Tidewater’s (CAT) Policies and Practices to Protect the Privacy of Your Health Information”
Clark Intake Form
New patients must complete this form prior to or at the time of their first appointment with Dr. Clark.
Informed Consent for Telehealth
Please note that distance counseling is only available within the state where your therapist is licensed. Distance counseling should not be viewed as a substitute for face-to-face counseling or medication by a physician.
New Patient Form
New patients must complete this form prior to or at the time of their first appointment.
Clinical Associates of Tidewater Privacy Notice
Provider-Patient Services Agreement/HIPAA Information
This document contains important information about our professional services and business practices, and must be read and signed prior to or at the time of your first appointment. Any questions you may have about this information can be addressed with your provider at the time of service.
Social History Questionaire (Adult, Rev 3-2013)
This form must be completed by new (adult) patients scheduled to see Dr. Anderson, Dr. Goldblum, or Dr. Mascalo.