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Client Forms

Welcome to Darby Fox’s practice! To streamline the onboarding process and ensure we have all necessary agreements in place, we’ve made essential forms available for you to download, complete, and return.

1

Complete the Credit Card Authorization Form

Fill out the required details in the Credit Card Authorization Form to ensure smooth processing of payments.
2

Sign and Authorize Your Information

Review the information provided, sign the authorization, and confirm your consent for secure processing.
3

Download HIPAA Notice & Authorization Forms

Access and download the HIPAA Notice and Authorization to Use or Disclose My Health Information Form for your records.

Complete Your Credit Card Authorization Form

Start Application

Payment Policy

  • Credit Card on File: We will securely keep your credit card information on file. Charges will not be processed until you have approved the transaction.
  • Payment Terms: Payment is due within 60 days (Net 60) from the billing date.
  • Late Payment Policy: A 3% interest fee will be applied to any outstanding balance after Net 60 days from the billing date.
  • Accepted Payment Methods: Credit Card (on file), Check, or Bank Transfer.

For any questions regarding your statement or to discuss payment options, please contact our office at (203) 979-0958 or gpracilio3@gmail.com.

Thank you for your prompt attention to this matter.

Darby Fox, LCSW