Forms

Below are new client forms. If you are coming in for a first visit, and would like to complete these forms prior to your visit, it will save you time. Also, it will allow us to have more time during the visit to discuss what you would like to work on in therapy.

Intake Form - this form helps Dr. Reynolds get to know you, how to contact you, and what you would like to work on in therapy

Intake Form.pdf

Informed Consent - this form lets you know what to expect in therapy, describes fees and confidentiality, etc.

Informed Consent.pdf

Insurance Form - this form only needs to be completed if you will be using your insurance company to pay for services.

Insurance information form.pdf

Release of Information- this form only needs to be completed if you want Dr. Reynolds to have communication with other parties (e.g., physician, psychiatrist, family member).

Release of Information form

GFE Notice - This notice is for private pay and Medicare/Medicaid clients.

GFE Notice -

Notice to ConsumersIn accordance with Texas law (House Bill 4224 and Section 181.105 of the Texas Health and Safety Code), the following information is provided to help consumers understand their rights and available resources.Requesting Your Health Care RecordsYou have the right to request a copy of your mental health records.To request your records, please submit a written request to your treating clinician or to the practice directly. Requests may be made via email, secure client portal, or in writing. Records will be provided in accordance with Texas law and applicable privacy regulations.If you have questions about accessing your records, please contact our office for assistance.Contacting the Texas Behavioral Health Executive Council (BHEC)The Texas Behavioral Health Executive Council regulates licensed mental health professionals in Texas.If you have questions about licensure or professional standards, you may contact BHEC directly:Texas Behavioral Health Executive Council – https://bhec.texas.gov/contact-us/Filing a Consumer ComplaintIf you wish to file a consumer complaint regarding mental health services, you may do so with the Texas Office of the Attorney General:Office of the Attorney General – https://www.texasattorneygeneral.gov/consumer-protection