Mimi Cogswell, LPC, LMHC
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  • Group Offerings
    • Middle Path Communications Group
    • Teen & Parent DBT Group Program Spring 2022
  • Release of Information Form
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Release of Information Form

Please find below the following forms to bring to your first appointment:
​* IMPORTANT – Please call my billing company, MindEase prior to the first appointment for them to confirm your health insurance coverage (unless you plan to pay privately).  Their number is 971-533-9911.
Intake
File Size: 49 kb
File Type: pdf
Download File

HIPAA and Privacy Policies
File Size: 23 kb
File Type: docx
Download File

Professional Disclosure Statement
File Size: 15 kb
File Type: docx
Download File

Informed Consent
File Size: 19 kb
File Type: docx
Download File

Signature Page
File Size: 17 kb
File Type: docx
Download File

Please complete the Intake form and after reviewing the HIPAA and Privacy Policies, the Professional Disclosure Statement and Informed Consent, please print and sign the Signature Page and bring with the Intake to your first session. 
​If you have any questions on the forms, please do not hesitate to call me at 503-740-5742 for more information.
Please don't forget to call MindEase, my billing company, prior to your first appointment for them to verify your health insurance coverage at 971-533-9911.
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  • Home
  • About
  • Group Offerings
    • Middle Path Communications Group
    • Teen & Parent DBT Group Program Spring 2022
  • Release of Information Form
  • Fees/Insurance Accepted
    • Payments
  • Contact