Promoting positive change
Promoting positive change

Patient Forms

Once your appointment has been scheduled, new patients will need to fill out several forms before therapy can begin. To make the process as smooth and efficient as possible, a link will be sent to you, so you can complete the forms on-line and automatically return to us. We can also send your forms via postal service or provide you the third option of downloading the forms and return the completed documents to our practice either in person, by fax or as a scanned PDF file via e-mail. Naturally, all forms are also available at the practice; however, filling them out in advance saves time.

 

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.  

Preparing for Session
To help all patients prepare for their session and share with their therapist at the start of session.
Preparing for Session.pdf
Adobe Acrobat document [65.2 KB]
Mood check-in before and Mood re-evaluation after session. Therapist evaluation sheet
Before and after mood check and evaluation of the therapist and therapy session. These forms have been found to improve the outcome of patients who complete these throughout their treatment.
Individual Before and After, version 20[...]
Adobe Acrobat document [599.8 KB]

Forms to see Chris Tammariello

Patient Rights to Confidentiality
This is for your reference.
HIPAA NOTICE-PATIENT.pdf
Adobe Acrobat document [202.2 KB]
Telemental Health Services Informed Consent
Informed Consent-Covid Protocol-CBTS.pdf
Adobe Acrobat document [287.0 KB]
Adult Agreement for Treatment
Advisement form for all adults to complete before their first session.
Adult Advisement (4).pdf
Adobe Acrobat document [285.0 KB]
Adult Agreement for Treatment- 3rd party pay
For Adults who will be having their sessions paid by another payer.
Adult Advisement3rdpayee.fill.pdf
Adobe Acrobat document [304.0 KB]
Parent Agreement for their Child to Receive Treatment (All patients under 18 years of age)
Agreement for treatment of a minor.
Child Advisement.pdf
Adobe Acrobat document [146.3 KB]
Additional Agreement for Exposure Treatment
For patients who have been instructed by their therapist to complete
Exposureadvisementform.pdf
Adobe Acrobat document [430.0 KB]
Permission to contact another service provider
This is for all patients who are receiving/ or have received mental health/healthcare from other providers that may be needed to contact by your therapist.
Consent for Release of Informationchecke[...]
Adobe Acrobat document [363.8 KB]
Patient Assessment Form
For all patients (minors and adults) to complete before their first appointment
Patient Intake Questionnaire (PIQ).pdf
Adobe Acrobat document [988.6 KB]
Patient Update
For returning patients
Patient Update Questionnaire (PUQ).pdf
Adobe Acrobat document [718.8 KB]

Forms to see Leanna Aubel

Rights of Confidentiality and sharing of information
The reference of the federal law describing patients rights of confidentiality and the handling of information.
HIPAA NOTICE-PATIENT.pdf
Adobe Acrobat document [202.2 KB]
Telemental Health Services Informed Consent
Informed Consent-Covid Protocol-CBTS.pdf
Adobe Acrobat document [287.0 KB]
Adult Agreement of Treatment - Self Pay
For all adults who will be paying for their own treatment regardless of insurance.
Adult Advisement.Leanna.A.fillable.pdf
Adobe Acrobat document [335.7 KB]
Adult Agreement of Treatment- 3rd Party Payer
For Adults who will be having another person (spouse, parent, or relative) pay for their treatment regardless of insurance.
Adult Advisement3rdpayee.Leanna.A.V2.pdf
Adobe Acrobat document [444.6 KB]
Parent Agreement for treatment of their Child (under 18 years)
Child Advisement.LA.fill - Copy.pdf
Adobe Acrobat document [217.1 KB]
Consent to Release of Information
This will allow your therapist to have contact with other treating clinicians to help insure the most effective treatment.
Consent for Release of Information.LA.pd[...]
Adobe Acrobat document [366.4 KB]
Patient Assessment Packet
For all patients to complete before their first meeting with their therapist.
Patient Intake Questionnaire (PIQ).pdf
Adobe Acrobat document [988.6 KB]

Where to Find Us

Cognitive Behavioral Therapy Services
5650 El Camino Real
Suite 224
Carlsbad , CA 92008
Phone: 760-730-0521 760-730-0521
Fax: 760-730-0581
E-mail Address:

Office Hours

Monday-Friday

8:30 am - 6:30 pm

Patient Forms

New patient? After you set up your appointment, forms will be sent to you by email or through the postal service.  The forms on our website are also avaialble as a thrird option after your appointment has been made.

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