Client and Intake Forms
On this page, current and future clients will find useful forms to download. Before our first appointment, we ask that clients download and complete the New Client Information form along with the appropriate Client History and Background form.
All forms are in PDF format, and can opened with Adobe Acrobat Reader. If you do not have this software, you can download it for free at the following website: http://get.adobe.com/reader/. All forms also allow you type your information if you prefer.
Please do not send any confidential information in an email transmission since email cannot be considered secured. If you choose to communicate with The Mauriello Group via email, you are consenting to the risks associated with use of email.
This form is for new clients to provide us with identifying information, emergency contacts, and insurance coverage.
Mauriello Group - New Client Information[...]
Adobe Acrobat document [143.6 KB]
This form is to give us background information on your history of symptoms, treatment, and social development
Mauriello Group - Client History.pdf
Adobe Acrobat document [408.7 KB]
This form is similar to the adult version above, but for background information about minor clients.
Mauriello Group - Client History (Minor)[...]
Adobe Acrobat document [374.8 KB]
The form explains Act 147 and how The Mauriello Group complies with the law to protect minor clients. We require parents to sign this form before accepting a minor as a client.
Mauriello Group - Act 147.pdf
Adobe Acrobat document [79.1 KB]
This form is an agreement between you, the client, and us, the treatment provider. It specifies the information necessary for you to agree and make an informed decision to enter treatment.
Mauriello Group - Consent to Treatment.p[...]
Adobe Acrobat document [85.9 KB]
This form is an agreement between you, the client, and us, the treatment provider. It specifies the information necessary for you to agree and make an informed decision to participate in a diagnostic evaluation.
Mauriello Group - Consent to Assessments[...]
Adobe Acrobat document [134.5 KB]
The form is an agreement between you, the client, and us, the treatment provider. It specifies the information necessary for you to agree and make an informed decision to receive services via telehealth.
Mauriello Group - Consent for Telehealth[...]
Adobe Acrobat document [164.5 KB]
This form authorizes us to release your protected health information to a person or organization of your choice.
Mauriello Group - Authorization to Relea[...]
Adobe Acrobat document [115.3 KB]
This form explains the limits of confidentiality when using your insurance benefits, and authorizes us to release your protected health information to your insurance carrier(s) for billing purposes.
Mauriello Group - Authorization to Relea[...]
Adobe Acrobat document [75.3 KB]
This form gives us permission to use, collect, or disclose your protected health information (PHI) as specified in our Notice Privacy Practices that you received.
Mauriello Group - NPP Consent Form.pdf
Adobe Acrobat document [83.0 KB]
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Mauriello Group - NPP Posting.pdf
Adobe Acrobat document [76.2 KB]
This form explains our Cancellation Policy that requires 24 business hours' notice when cancelling a scheduled appointment as well as exceptions in the event of weather- or illness-related emergencies.
Mauriello Group - Cancellation Policy.pd[...]
Adobe Acrobat document [60.8 KB]
Contact Us:
The Mauriello Group
139 West Market Street
Suite D
West Chester, PA 19382
Fax: 888.976.5828
A National Certified Counselor (NCC) represents an individual's voluntary completion of and commitment to national standards determined by the counseling profession. Several members of our team have achieved this level of certification.
Matthew Mauriello is certified to properly provide distance services to clients seeking telehealth.
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