Patient Registration

To sign up online as a patient, please complete the following forms, in order.
To insure the security of your data, you will only be able to review your input on these forms while your session is active; usually sessions expire after 20 minutes of internet inactivity. You can always press Submit on a form to save it, and thus renew your session timeout period, even if you haven't completed the form. Upon submission, you will be returned to this page, and you can click on the form you left incomplete to continue entering information. You may enter data into any form that is underlined below.

Online Forms to Complete (Please Complete in order)
    Patient Information Sheet
    Patient Intake Sheet
    Comprehensive Medical History
    Insurance Information
    Acknowledgement of Receipt of Privacy Notice

If you would like your information shared with any other person (such as your physician or referring doctor, you must print and complete the following form and return to our office.

View or Print our Authorization for Disclosure Form

You are welcome to print and keep the following Notice of Privacy Practices

Notice of Privacy Practices

Informed Consent Checklist for Telepsychological Services

Please print the Consent form by clicking on the following link, sign it, and return to our office via fax at (866) 341-1114 or email to
Telepsychological Consent Form PDF (to Print and complete)

Insurance Only

To view or print a form that will help you discuss your insurance benefits with your insurance company, click on the following link. Please bring this completed form to your first appointment.
Insurance Information PDF (to Print and complete)

Copyright © 2020, Susan D. Gifford, Ph.D., P.C. All Rights Reserved

Designed by Eddie Gifford