Helpful Forms

Helpful Forms

** If you are a NEW CLIENT , please complete and Scan in a PDF the following three forms ( 1,2 & 3)  (Please do Not take a photo of the forms and send)

  • Client Psychotherapy Intake Form
  • Limits of Confidentiality/Therapy Cancellation Policy
  • Notice of Privacy Practices


** If you would like me to coordinate care with another provider: (for example, your Psychiatrist, primary care Physician, PPO Insurance), complete form (5) to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form


* If you are a Parent seeking therapy for a MINOR , please fill out the form (6)

*  Minor Consent Form

 

Client Psychotherapy Intake Form (1). New Client:  Intake Form
Limits of Confidentiality/Therapy Cancellation Policy (2). New Client:  Limits of Confidentiality/Therapy Cancellation Policy
Notice of Privacy Practices (3). New Client:  Notice of Privacy Practices
Telehealth Informed Consent < (4). Telehealth Informed Consent

Career Intake Form

(5). Career Intake Form

Authorization to Disclose Information Form (6). Insurance, Psychiatrist, primary care Physician
Minor Consent Form (7). Minor Consent Form (Parent)

 

Note: To download Adobe Acrobat Reader for free, click here .

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