​​Cyndie Ford Purdy, LMHC

Licensed mental health Counselor

352.341.0435  |  fordpurdy@msn.com

For those of you who would like to complete the paperwork prior to the initial session, I have added the intake paperwork on this page for your convenience.  Please click on each form below that applies to you so you can print the documents and complete them at your convenience.  Please complete each form as accurately and thoroughly as possible and bring the documents with you to your first appointment.  If you are not self-pay or coming to therapy as a couple you will not need to print those two forms.  Since many of you have already reviewed HIPAA Regulations, it is not necessary for you to print the HIPAA Revision unless you wish to keep a copy for your records.  I do ask that you print and sign the Notice of Privacy Practices that indicate you have read and understand the HIPAA regulations.  Thank you.

Welcome Letter
HIPAA Revised 10.17.2013
Notice of Privacy Practices
Consent for Treatment
Financial Policy 05.15.18
Self Pay Contract
Limits to Confidentiality
Adult Intake Inventory
Medications List
Self Assessment
Couple's Contract
​​Additional Charges 07.26.18

Consent for Telemental Health Services