Forms
Below are links to forms that you will need for your appointment with Dr. Aylor.
Please be sure to read them carefully and sign or initial where indicated.
Click your mouse on the AQUA text and a .pdf (Adobe) document will be generated.
Please print the document, complete it at home and bring the documents with you to your appointment.
If you are using insurance to pay for your appointments, you will also need to bring a copy of your insurance card and a form of identification with you to the first appointment.
If the event that you are without a printer, Dr. Aylor can arrange for you to fill these forms out in the waiting room or send them to you by mail.
In general, it takes about 30-minutes to complete all of the forms. Should you have difficulty reading or concentrating, please recognize that it may take longer than 30-minutes and plan accordingly. Please arrive early enough to have adequate time before your appointment to complete these necessary forms.
Patient Information This form will provide Dr. Aylor and her billing representatives with the necessary information about your Health Insurance, your primary physician and your emergency contacts. The third page is a release that allows Dr. Aylor or her representatives to communicate with your insurance company on your behalf with regard to billing, or if any issues arise with your insurance. Please be aware that your insurance provider can ask questions about anything that is in your health record to determine the medical necessity of your continued treatment.
Consent to Treatment This is a lengthy document, (that the California Board of Psychology requires be printed in 12-point font) this document will give you valuable and necessary information about the services you may receive, confidentiality issues and limits to confidentiality. Please read each section carefully and put your initials in each box in the right hand margin to indicate that you have read and understand each section.
Notice of Privacy Practices (This form does not need to be printed out, this is for your information only!) The next form "HIPAA Doc" is the form you must sign to indicate that you have access to, or have received "The Notice of Privacy Practices."
HIPAA doc Your signature on this form will be adequate to indicate that you have had access to the "Notice of Privacy Practices"
No Show/ Late Cancellation Policy This form reiterates information about the importance of attending appointments you schedule with Dr. Aylor. Unlike other physicians, psychologists are not able to overbook their schedules assuming a certain number of clients will not attend their appointments. Psychologists cannot run overtime at the end of the day or cut appointments short if all clients show up. When you schedule an appointment with a therapist, that time is reserved for you and you alone. Failure to appear at your scheduled treatment time (“No Show”) and late cancellations are bad for business. Repeated “No Shows” or late cancellations will result in termination of your therapy services.
History & Physical This is pretty self-explanatory, please fill out all sections.
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult This is a self-rating scale that provides a quick assessment of your functioning and may be administered at various times throughout treatment. This measure can be reproduced without permission by researchers and by clinicians for use with their patients. Rights holder: American Psychiatric Association
Credit Card Authorization Form Fill out this form only if you intend to use credit or debit cards for payment of your services.
Parental Consent This form is intended for young adult patients who are not financially independent and will be relying on their parents health insurance and financial support for their services. This form is required for any individual who is using their parents' health insurance.
Release of Information This form is only required if you choose to share your information between Dr. Aylor and anyone else, or would like Dr. Aylor to contact a former health care provider, parent or significant other on your behalf or to receive your medical records.
Consent for Teletherapy Due to the 2020 novel corona virus (Covid-19) pandemic, Dr. Aylor is not seeing patients in her office at this time. Dr. Aylor has chosen to schedule clients with Zoom for telepsychology as Zoom meets all standards for encryption and HIPAA compliance required by health care providers. If this is a technology with which you are uncomfortable, other possible arrangements may possibly be able to be made with your consent.