First Time Visit
Welcome,
If you're visiting me for the first time please come about 15 minutes early. It's generally a paperwork day and I want to make sure we have enough time to get to know each other.
Our first session takes about an hour. Therapy sessions will be scheduled for 45 minute sessions.
Assessments for Diminishing Independance such as Alzheimer's or a Neuropsychological test can take from 5 to 7 hours. While testing, I always try to get your best efforts so if we have to break the testing into 2 or 3 shorter sessions I will recommend it once I see how you are doing.
Assessing for Accommodating Complex Medical Conditions, Pre-Surgical, or General Psychological Assessments can take 3 to 4 hours and we will always complete it in one session.
Below are five or six forms that all new patients will need to complete. You can download them now and hand them in when you first arrive. Otherwise, please come at least 20 minutes early to your first appointment to complete them.
Adult Patient Information 061108.pdf - 61.45KB
Child and Adolescent Form
If you are bring a individual to our practice who is under 18 years old please download and fill out this from.
Child Adolescent Patient Information 061108.pdf - 61.51KB
Financial Responsibility
Please download and read this form carefully.
Financial Responsibility Statement.pdf - 73.34KB
Notice of Privacy
Please download and read this form carefully.
Notices of privacy practices.pdf - 50.82KB
Another Privacy Statement
Please download and read carefully.
Privacy Practices Acknowledgement Consent.pdf - 42.67KB
Release of Information
You will need to download a copy for each individual you would like us to be able to talk to. You cannot put multiple names on a single release form.
Even if you have filled out a release form at another agency, it only allows them to deliver information to us. It does not allow us to deliever information back to them.
Release of Information.pdf - 52.75KB
Assessments
Assessment for diminishing independance for Alzheimer's 5-7 hours
Assessment for accommodating complex medical conditions 3-4 hours
Pre-surgical assessment 3-4 hours
General psychological assessment 3-4 hours
Neuropsychological assessment 5-7 hours
Most Popular Treatment Requests
Chronic pain strategies and management
Attention, Concentration or Memory problems
Managing complex medical conditions
Couples Therapy
Dr.Ezzo provides counseling services to help in your relationship with your significant other. Under some circumstances we might ask you to complete this form.
Couples Info.pdf - 68.73KB
Keeping track of issues
In certain situations it may be necessary to formally assess all of your issues. We may begin with this form.
Emotional Behavioral Assessment.pdf - 72.86KB
Children
Anytime a child is being considered for treatment this form must be filled out.
Personal Hx Child Adol.pdf - 84.36KB