Patient Forms

After you have called to schedule an appointment with Dr. Kale Kirkland, you should be directed to this page, where there are a few forms for you to fill out. After completing the forms, please do one of the following:
a) Scan and email to calapsych@gmail.com
b) Fax to Central Alabama Psychology at (334) 819-4873
c) Bring with you to our office at your first scheduled appointment

New Patient Forms

New Patient Form - Adult

cap_new_patient_adult.doc
File Size:	87 kb
File Type:	doc

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New Patient Form - Child/Adolescent (under 18)

Health Insurance Portability and Accountability Act

The HIPAA Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes. 

The Security Rule specifies a series of administrative, physical, and technical safeguards for covered entities and their business associates to use to assure the confidentiality, integrity, and availability of electronic protected health information. 

Please Sign this form and return to submit to our office.

central_al_psychology_hippa.doc
File Size:	38 kb
File Type:	doc

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Informed Consent 

Informed Consent - Adult

cap_informed_consent_adult.docx
File Size:	172 kb
File Type:	docx

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Informed Consent - Child/Adolescent (Under 18)

informed_consent_for_treatment_-_adolescents_calapsych.docx
File Size:	29 kb
File Type:	docx

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Release of Information 

cap_release_authorization.docx
File Size:	132 kb
File Type:	docx

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APA Code of Ethics (2002)

apa_code_of_ethics.pdf
File Size:	228 kb
File Type:	pdf

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