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Client Forms

For your convenience, before our first session, please read, print out, and complete the New Client Registration Form and Agreement for Psychological Services. The Agreement explains my fees, insurance billing, etc.. (Please note that I am an “out of network provider” for insurance plans.  Also, remember that you can use your Health Savings or Flexible Savings Account, if applicable.)  If you would like me to consult with another professional regarding your care (psychiatrist, primary care physician, another therapist, etc.), please print and complete the Authorization for Release of Information. You may also wish to print and complete the Authorization for Credit Card Payment of Fees if you plan to use your credit card for payment.

Please bring these forms with you to your appointment.  At that time we can also address any questions you may have.

All forms are  pdf PDF Format. (Get the free Adobe Reader.)

formNCRthmb

New Client Registration

formAPSthmb

Agreement for Services

formRIthmb

Release of Information

formVMAthmb

Visa/MasterCard Agreement

Please feel free to call me at 206-285-0900 or email me at dkosins@u.washington.edu if you have a question or wish to schedule an appointment.

All material provided on this website is for informational purposes only. Direct consultation of a qualified provider should be sought for any specific questions or problems. Use of this website in no way constitutes professional service or advice. David J. Kosins, Ph.D. © 2017