| Please complete the following forms, and bring them to our first session |
New Patient Information – This is a general patient information form.*
- *If you would like for me to contact your insurance company to verify your coverage, please complete and fax this
form to me at 678-623-8234 as soon as possible. Or, if you would prefer, you may email the information under the
Insurance Information heading to me at info@drkerley.com.
Consent Forms Packet – This packet contains the following:
General Policies and Procedures
Informed Consent Form
Notice of Privacy Practices
Consent to Use and Disclose Health Information Form
Authorization of Release Form**
The last four pages are copies for your records.
**The Authorization of Release Form only needs to be completed if there is someone you would like for me to
communicate with regarding our sessions [e.g., doctor, family member, school].
Parent’s Checklist – This file contains a background questionnaire for parents of children attending
therapy.
therapy.
Adult Intake – This file contains a background questionnaire for adults attending therapy.
D. Craig Kerley, Psy.D.
Licensed Psychologist
Licensed Psychologist
3949 Holcomb Bridge Road
Suite 202
Norcross, GA 30092
770-449-0082 Telephone
678-623-8234 Fax
info@drkerley.com
Suite 202
Norcross, GA 30092
770-449-0082 Telephone
678-623-8234 Fax
info@drkerley.com
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