For new and current clients
Client forms.
A quick reminder: if you fill a form out inside your browser, use Print and Save as PDF before you close the tab. The Download button saves a blank copy.
No need to print anything. To sign, open your saved PDF in Adobe Acrobat Reader and use Fill & Sign, or on a Mac open it in Preview and click the Markup icon. Both let you type or draw your signature. Save the file.
Returning your forms. Send completed forms to info@irelandphd.com, which is a secure, HIPAA compliant address. Please send them before your first session so Dr. Ireland has time to review them.
Everyone completes these
Please finish these before your first session.
Your contact details, what brings you in, your health care providers, emergency contacts, and how you would like to be reached.
DownloadBackground on your health, your history, and what you would like to work on. This is the longest form, so give yourself some time with it.
DownloadHow therapy works here, confidentiality and its limits, appointments and cancellations, and your consent to treatment.
DownloadAll sessions are conducted by video or telephone, so this one is required before your first session. Covers the platform used, privacy on your end, and where you need to be located during a session.
DownloadCurrent rates and payment terms. ADE, Inc. is a fee-for-service practice and does not bill insurance.
DownloadA short acknowledgment that you received the privacy notice, which is number 10 below.
DownloadThis form authorizes Dr. Ireland to communicate with your physician, dietitian, or another provider to best support your care. You choose who to include and what may be shared, and you can withdraw it at any time. If there is no one to add right now, skip it.
DownloadOnly if Dr. Ireland asks you
She will tell you if one of these applies. Please do not fill them out on your own.
Dr. Ireland will complete this together with you during a session if it becomes appropriate. It is here so you can find it when she asks.
DownloadA detailed form Dr. Ireland sends when eating, weight, or body image is part of what you are working on together.
DownloadRead and keep, nothing to fill in
How your health information is used and protected, and your rights regarding it. Sign the receipt at number 6 to confirm you received this.
DownloadAn estimate of what your care is expected to cost, which you are entitled to as a self-pay client. Dr. Ireland completes this with you. It is here so you can see it in advance.
DownloadQuestions, or trouble with a form? Call or text (703) 722-2324. Please do not email to cancel or reschedule an appointment, as email is not checked continuously.