My Contact Information is
Claudia Hirsemann, LCSW (865) 851-1414 [email protected] PsychologyToday page claudiahirsemannlcsw.weebly.com |
Forms____________________________________________________________________________________
Client History and Prescreening Assessment Please click the link below or copy and paste it into your browser and fill out the form. Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing. I will contact you in the order in which I receive this form. If I currently have a waiting list you will be added accordingly. Please click the link below docs.google.com/forms/d/e/1FAIpQLSeb6krVovqwvROLv_E4Ab7733vuDEB_khBQSclTV1T7l9AD0Q/viewform?usp=sharing ____________________________________________________________________________________ EBT Client Initial Intake Please click the links below or copy and paste it into your browser and fill out the forms. Once you click submit it will be routed to me in a Federal Privacy and HIPAA compliant format for processing. I need all of this information (Intake Form, ID, and Insurance card(s) pictures – front and back) back 48 hours before your appointment. Thank you. I am located in Kodak, TN. My phone number is 865-851-1414 claudia@ebtherapy.org Please click the link below https://docs.google.com/forms/d/e/1FAIpQLSex7dXD1p0eMvnfN8-q6BW1gX0ylngLWBzqsXzF2PfF0Rl-vw/viewform?usp=sharing ____________________________________________________________________________________ Assessments
ACEs Childhood Trauma Assessment ASRS ADHD Assessment CSSRS Suicide Rating Scale Assessment Suicide Safety Plan No Harm Agreement MDQ Mood Disorder Assessment PCL-5 PTSD Assessment PHQ-9 & GAD-7 Depression & Anxiety Assessments Consents Consent to Share of Information Revoke Consent to Release Information Handouts Emotional Self Rescue (ESR) Don't Grope Me What it's like to be adopted Empath / Inner Child Healing 5 destructive fantasies empaths have after the narcissist has left (copied from Vitalmind psychology) Misc EBT Agreement ____________________________________________________________________________________ Notice of Privacy Practices for Protected Health Information and Health Information Portability and Accountability Act (NPP & HIPAA) ____________________________________________________________________________________ |