Forms & Telehealth Portal
I look forward to meeting you and supporting you in your clinical process. Before your appointment please take time to read carefully, fill out and return to me the forms below. There are a total of 4 consent forms and all clients over the age of 14 will need to sign to give their consent. If you have any questions please do not hesitate to call me (503.332.3394) for further clarification/instructions.
Specifically for tele-health sessions, at the time of your appointment I ask that you please check in my virtual waiting room at: https://doxy.me/irmallanes
REOCCURRING CREDIT CARD/ACH/DEBIT PAYMENT AUTHORIZATION*
*Please make sure to omit filling in personal banking information, unless using a fax to return paperwork; I will obtain this information and fill it in on my end at the time of your appointment.
INFORMED CONSENT FOR THE USE OF ELECTRONIC COMMUNICATIONS
RELEASE OF INFORMATION (ROI) ∾ may not be applicable, only if specifically requested
Email or Fax your completed forms.
Conveniently located in Tigard at the intersection of highways 5 and 217, with immediate access to public transportation and easily reached from surrounding cities such as Portland, Lake Oswego, Beaverton, Tualatin and Wilsonville.
Morning, day & evening appointments available.