LESLIE H. KERN, Ph.D.

CLINICAL PSYCHOLOGIST

ADDRESS

4512 Zeller Road
Columbus, OH. 43214

CONTACT

TEL: 614-886-8449
EMAIL: lesliekern1955@gmail.com

Leslie Kern, PHD

FORMS

Here are four documents.  Please do the following and either return through the mail (if we will be meeting remotely), or bring to our first visit.  Signed documents should be mailed/brought to:

Leslie Kern, Ph.D.
4512 Zeller Road
Columbus, OH. 43214

  1. Form #1: Print out, complete, and sign the first document, “Client Background Information.”
  2. Form #2: Review and sign the second document, “Psychotherapist-Client Services Agreement.”  You only need to print out and mail the signature page.
  3. Form #3: Review the third document, “Notice Of Policies And Practices To Protect The Privacy Of Your Health Information.”  You do not need to return this to me.
  4. Form #4: If we are meeting remotely due to a Covid surge, complete and return the fourth document, “Telepsychology Consent Form.”

Thank you!

LESLIE KERN, PH.D.

Leslie Kern, PHD