First Session Forms

If you’ve scheduled your first appointment, please print out, review and complete the first three PDF forms and bring with you to your first session.  The last two forms are for your information and records.

 

* Even if you’re not planning on paying by credit card, please fill out the Credit Card Preauthorization.  It will remain on file if you no-show for your confirmed appointment, don’t give 24 hour cancellation notice, or if a session is conducted by phone.

Intake Form

This form is for THERAPY SERVICES ONLY and requests information about you and/or your family that will help me plan your care. 

Receipt of HIPAA & Disclosure Statement

By signing this form, Client acknowledges that he/she has reviewed and fully

understands the terms and conditions being stated in the Privacy Practices and

Disclosure Statement. 

Credit Card Preauthorization

Credit Card Pre-Authorization For Use By Debra Cucci, MFT

Disclosure Statement

This document is intended to provide important information to you regarding

your treatment. 

Notice of Privacy Practices

This notice describes how health information about you (as a patient of this practice)

may be used and disclosed and how you can get access to your individually identifiable

health information. 

Hypnosis

This form is for HYPNOSIS ONLY and requests information about you that will help me plan your hypnosis session. 

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I am including an Insurance Questionnaire to help you determine if your insurance company will provide any reimbursement for psychotherapy services.

Insurance Questionnaire

In order to determine what insurance benefits you have available for reimbursement, you may want

to contact your insurance company at the phone number listed on your insurance card and ask the following questions. 

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Contact

500 S. Sepulveda Blvd. Suite 204

Manhattan Beach, California 90266

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Phone 310.480.2655

Email: Debra Cucci, LMFT

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opening hours

Monday 12-7

Tuesday 12-7

Friday 12-7

Other weekdays & Saturdays as needed

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