If you are a new client, please read and complete the following forms and bring them to your first therapy session. Completion of each form below is required for all clients seeking psychotherapy. Thank you.
Please note: Each of these forms is fillable. You may type in your responses, then print upon completion and bring with you to your first session. If you prefer not to type them, you may print them and complete by hand.
Client Registration Form: This form provides this therapist with general information about the client and basic contact information.
Client Intake Form: This form provides this therapist with information about current concerns or reasons the client is seeking therapy, as well as detailed history information.
Disclosure Statement: This form is a state mandated disclosure that gives the client information about this therapist's qualifications, the client's rights within therapy and issues of confidentiality.
Informed Consent: This form gives the client a detailed description the following:
Notice of Privacy Practice (HIPAA): This form gives you all the information needed to understand how your records are kept private and how to obtain access to your records. Pages 1-3 may be printed and kept for your personal records. Please sign and return page 4 for therapist.
Authorization to Release Confidential Information: If you would like me to coordinate care with a family member or another provider (for example, your primary care physician, psychiatrist, etc.), please complete this form to authorize release and/or exchange of confidential information. All releases expire one year from the date signed, unless the client gives permission for it to continue and may be revoked earlier at the client's request.
Please note: Each of these forms is fillable. You may type in your responses, then print upon completion and bring with you to your first session. If you prefer not to type them, you may print them and complete by hand.
Client Registration Form: This form provides this therapist with general information about the client and basic contact information.
Client Intake Form: This form provides this therapist with information about current concerns or reasons the client is seeking therapy, as well as detailed history information.
Disclosure Statement: This form is a state mandated disclosure that gives the client information about this therapist's qualifications, the client's rights within therapy and issues of confidentiality.
Informed Consent: This form gives the client a detailed description the following:
- Information about this therapist
- Financial and payment policy
- Appointment scheduling and cancellation policy
- Electronic communications policy
- Benefits and risks of therapy
- Treatment methods, planning, evaluation and termination
- General practice policies, including availability and emergency protocol
Notice of Privacy Practice (HIPAA): This form gives you all the information needed to understand how your records are kept private and how to obtain access to your records. Pages 1-3 may be printed and kept for your personal records. Please sign and return page 4 for therapist.
Authorization to Release Confidential Information: If you would like me to coordinate care with a family member or another provider (for example, your primary care physician, psychiatrist, etc.), please complete this form to authorize release and/or exchange of confidential information. All releases expire one year from the date signed, unless the client gives permission for it to continue and may be revoked earlier at the client's request.