Navigate / search

Forms & Resources

The forms below should be printed and brought to the first appointment

 

The following forms are for appointments with Katie Hart, LMHC, CN

Insurance-INFO-INTAKE-HARTSSPACE (all patients)

HartsSpace-MAIN-INTAKE-Full-Health-History (adults)

Release-of-INFO-2  (adolescents)

Child-Information (children)

Katie-Hart-Disclosure-with HIPPA (all clients signature required)

Diet Diary Template  (complete as indicated following the initial appointment)

HartsSpace-Medical-Release-of-INFO (if applicable for labs and chart notes)

Release-of-INFO (other than medical)

The following forms are for appointments with Cat McPherson, CN

Cat’s Disclosure statement

Insurance-INFO-INTAKE-HARTSSPACE (all patients)

HartsSpace-MAIN-INTAKE-Full-Health-History (all patients)

Diet Diary Template  (complete as indicated following the initial appointment)

HartsSpace-Medical-Release-of-INFO (if applicable for labs and chart notes)

The following forms are for appointments with Lisa Caldwell, MS, CN, LMHCA, MHP

Lisa’s Disclosure statement

Insurance-INFO-INTAKE-HARTSSPACE (all patients)

HartsSpace-MAIN-INTAKE-Full-Health-History (all patients)

Diet Diary Template  (complete as indicated following the initial appointment)

HartsSpace-Medical-Release-of-INFO (if applicable for labs and chart notes)

 

If you have trouble opening these files please email sustainablehealth@hartsspace.com