Jodi L. Olmstead, LMHC
Clinical Director

Center for Mood Disorders Inc
         ~of Stuart and Vero Beach

Healing Tomorrow. Starting Today.
         For Individuals. For Couples. For Families.          
(772) 224-1294 / (772) 494-7693 fax              
                                                             AETNA & BCBS Provider

Please print all forms and bring to your initial therapy intake session.

Please print this form and provide your contact information, billing and insurance information, presenting problem and history of mental health or medical issues.

Please print this form and sign if you consent to treatment at our agency.

Please print, sign and date the center line of the form.  There are two areas for signature, first to consent to submit information to your insurance company, and the second to consent to allow your insurance to send payment to our agency.

Please print this form and sign if you understand the laws and rights to protect your private health information.

Please print this form and complete if you would like to grant consent for an exchange of treatment information between our agency and a doctor, relative or other agency.  Please be specific in indicating which information you are consenting to by initialing the appopriate field.