Forms

Feel free to review, print out, and fill out the required treatment forms below prior to your initial evaluation session:

For All Patients (Child & Adult):

  1. Outpatient Services Contract

  2. HIPAA Form

  3. Authorization to Request Confidential Records Form

  4. New Patient Registration Form

  5. Credit Card Verification Form

  6. Policies Information Form

Additional Consent Form for Child and Adolescent Patients:

  1. Child Therapy Contract


For KIPP Students Only:


Richard N. Costa, PsyD, MP
 Phone: 504.491.0489   *   Fax: 504.738.1880 *   Email: drrickcosta@gmail.com
Center for Emotional Health & Wellness, LLC  6221 So. Claiborne Ave., Ste. 201 New Orleans, LA 70125

Louisiana Licensed Psychologist (Clinical) #946; Licensed Medical Psychologist MP.000022; Advanced Practice Psychologist AP.335110
Utah Licensed Psychologist (Clinical) #13508932-2501
Florida Telehealth Provider Registration #2344 (see link: https://flhealthsource.gov/telehealth/)