1458 Campbell Rd. Suite 250A, Houston, TX 77055 | ph.713 294 8090 | dilek@dilekwise.org
You may download and print the forms below. Please bring these forms with you to your appointment. This way you can save yourself time when you come in to the office. If you have any questions/concerns regarding the office policies or the confidentiality, please call 713 294 8090 or email to dilek@dilekwise.org
Intake Forms
Instructions: Forms 1 to 5 need to be filled-out separately by each individual attending therapy. Couples can sign on one copy on the Forms # 2,3,4. If you are using insurance to pay for therapy, please make sure to fill out Form #3, if you are paying out-of-pocket you do not need this form. Notice of Privacy Practices -last document is yours to keep; you may read it online to save some trees for our planet :)
If you are using Skype to continue your therapeutic dialogue with Dr. Wise, please email her to ask for additional consent/policy forms to be e-mailed to you before your appointment. You still need to fill out the forms below, and additional ones that we'll email you. You will need to fax all the forms to our office at 713 467 6532 -it's a confidential fax line, before your Skype meeting.
See you soon,
If you are using Skype to continue your therapeutic dialogue with Dr. Wise, please email her to ask for additional consent/policy forms to be e-mailed to you before your appointment. You still need to fill out the forms below, and additional ones that we'll email you. You will need to fax all the forms to our office at 713 467 6532 -it's a confidential fax line, before your Skype meeting.
See you soon,
| info_form1.pdf |
| policies_form2.pdf |
| insurance_form3.pdf |
| consent_form4.pdf |
| ccauth_form5.pdf |
| noticeofprivacypractices.pdf |
