Client In-Take Forms
Client Intake Consent Forms

Intake forms are required. Please download and complete the appropriate client consent forms prior to your appointment and bring them with you to your first session. Thank you for your cooperation!

  • Insurance Information & Authorization Form
  • Psychotherapy Consent Form
  • Treatment of a Minor Consent Form
  • NOTICE OF PRIVCY PRACTICES (HIPAA)
  • Heather Bellizzi, LCSW
    Psychotherapist

    Licensed: 44SC04663900
    Accepted Insurance:
    (In-Network Provider)
    Medicare and CONCERN

    I am an in-network provider for Medicare and CONCERN. Additionally, I will work with your financial needs whenever possible and will help you to maximize use of your out-of network benefits. Please call to learn how I can work with your insurance company so together we can get you on the path to a new you!