Welcome Packet from Karner Psychological Associates

Please complete these important forms

When you come to Karner Psychological Associates for your initial appointment, you will be be given a packet of information about our office policies. These forms should be read and signed before you meet with your therapist. In addition, you will need to provide background and insurance information before your appointment starts. If you like, you can download the forms in advance, which gives you the opportunity to fill them out at your leisure. Or, if you prefer, you can arrive at your first appointment 15 minutes early to fill out the forms at our office.

To print out the forms in advance, use the following links. All forms must be completely filled out before your first appointment begins. We also encourage you to read the KPA Notice of Privacy Policy before signing any of the forms.

No Show Policy: Appointments that are not canceled at least 24 hours beforehand are charged the full fee; insurance companies will not cover any portion of a missed appointment, making the entire cost the responsibility of the client. Therefore, be careful to schedule appointments only at times when you are sure that you can attend. If you are going to miss an appointment, please contact the therapist or receptionist (or, if after hours, the answering service at 243-2169) immediately. If there are extenuating circumstances (last minute illness, dangerous weather), we will generally waive the late fee upon explanation.

The following forms need to be read, filled out, and/or signed:

KPA PDF Files

If you cannot download these documents please click the red PDF button above to download the latest Adobe Reader

Click here to download the New Patient Welcome Packet

The following two forms are optional.
The first two forms only need be signed if you want to authorize the sharing of your clinical information with another party, or if you want to make special restrictions on the sharing of your patient records. Please read our privacy policy to better understand how your health records are used and protected.

Authorization form

Restrictions on authorizing information

This last page is for your information only and does not need to be signed.
These are occasional fees that need to be added in certain situations.

Admin Fees

If you cannot download these documents please click the red PDF button above to download the latest Adobe Reader.

Share/Bookmark