Helpful Forms
If you are a new client for Nancy Duffey Black, please thoroughly read and complete the following forms. Then bring them with you to your first therapy session. This will save both of us time that would otherwise be spent completing necessary paperwork to initiate psychotherapy. If you forget to bring them, we will complete the forms at our first session.
- Statement of Understanding and Consent for Professional Services
(includes the limits of confidentiality, fees, and therapy cancellation policy) - HIPPA Notice of Privacy Practices
- Client Bill of Rights
If you would like me to coordinate care with one or more of your mental health or medical providers (such as your primary care physician, psychiatrist, and physical therapist) or share information with your spouse, partner or other family member, please complete this form to authorize release of psychotherapy information:
You will need Adobe Acrobat Reader to read the forms provided. Click on the following icon to download Adobe Reader for free.
Contact Information
Nancy Duffey Black, MS, LICSW
Duffey Black Consulting, LLC
Specializing in Critical Incident Response Services
Madison Lake, MN 56063
(763) 443-3348 (P)
Nan@DuffeyBlack.com
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