New Patient Forms

For New Patients:

After speaking with Dr. Costa and prior to your initial visit (in an effort to save you time completing these required forms during your initial office visit), please download, review, and print the following new patient registration and history forms to bring with you to your first appointment. However, if you do not have access to a printer or require assistance completing these forms, Dr. Costa will have printed copies available and will be happy to review, assist you in completing, and answer any questions related to these forms during your in-office visit. 

NEW PATIENT REGISTRATION FORMS:

NEW PATIENT HISTORY FORMS:

  • Child History and Adolescent (0-17 years) History Form (click here
  • Adult (18+ years) History Form (click here)

NEW PATIENT CONSENT TO TREATMENT FORMS:

  • Outpatient Treatment Consent Form for All Patients (click here
  • Child & Adolescent Outpatient Therapy Contract Form (click here)
  • Consent to Release Protected Health Information Form for All Patients (click here

IMPORTANT REMINDER:  In addition, please remember to bring with you to your initial visit with Dr. Costa all of your medication bottles (prescribed and over-the-counter) as well as any bottles or containers that list all ingredients of supplements, vitamins, minerals, herbs, or remedies you currently take (prescribed or over-the-counter).

Note for new patients wishing additional advance telephone consultation: If you would like Dr. Costa to speak by telephone with a referring physician, therapist, or school source prior to your first scheduled appointment, please complete a Release of Information form (click here) and fax it to (888) 568-9274 before your appointment. 

Note: If you are having difficulties opening the PDF files above, (click here) to download the Adobe Acrobat Reader for free.

 

Richard N. Costa, PsyD, MP (Louisiana Licensed Psychologist #946) * Phone: 504.491.0489 * Fax: 888.568.9274 * Email: drrickcosta@gmail.com
Center for Emotional Health & Wellness, LLC  6221 So. Claiborne Ave., Ste. 201 New Orleans, LA 70125