Jay H. Berk, Ph.D., Inc.

23293 Commerce Park, Beachwood, OH 44122
(216) 292-7170 FAX (216) 292-7182

Dear Client,

This page links you to a file that can be downloaded containing information needed for your first appointment. Please download this file by clicking the "Print Copy" button. Please review all information, complete all forms and sign forms. This Intake File consists of the following sixteen pages:

1. Intake Appointment Form

2. Directions to Office

3. Client information and Background

4. Professional Services Agreement with Jay H. Berk, Ph.D., Inc.

5. Child Client Information

6. Background Information for Treatment pages 1

7. Background Information for Treatment pages 2

8. Social Skills Group Information

9. Fees for Ancillary Services

10. Consent for treatment of a minor

11. Consent to Treatment and Fee Agreement

12. Client information and Consent to Treatment

13. Fees, Payments, and Insurance 1

14. Fees, Payments, and Insurance 2

15. Fees, Payments, and Insurance 3

16. Agreement signature form

Please bring this with you to the appointment. Should you have any questions about the office policies, I will be happy to discuss them with you at the appointment.

There are several documents in the paperwork that require a witness signature. Please have an adult (spouse, relative, neighbor, co-worker, etc.) sign these pages before the office visit. Also, if you are bringing any school evaluations, IEP’s, 504 Plans, doctor evaluations or reports, etc., please do not bring the originals. Bring a copy that I can keep for my reference. Your assistance with these items will make our visit be more focused on helping your child.

YOUR CHILD AND AT LEAST ONE PARENT MUST

ATTEND THIS APPOINTMENT.

Also, please be sure that you have contacted your insurance company, if preauthorization is required, before the appointment.

I look forward to meeting with your family.

Sincerely,

Jay H. Berk, Ph.D.

Clinical Psychologist