Required Forms
Please provide me with the information below for my records. All information will be kept confidential in your client file. If there are questions that you do not wish to answer at this time, feel free to leave them blank.
Please download, print and complete the following forms, and bring them to your initial therapy session.
Psychotherapy Intake Form
This form collects personal and contact information related to your therapy plan.
Confidentiality & Privacy Policy Form
This form ensures that you understand our confidentiality and privacy policy.
Cancellation Policy Form
This form ensures that you understand our cancellation policy.
Please download, print and complete the following forms, and bring them to your initial therapy session.
Psychotherapy Intake Form
This form collects personal and contact information related to your therapy plan.
Confidentiality & Privacy Policy Form
This form ensures that you understand our confidentiality and privacy policy.
Cancellation Policy Form
This form ensures that you understand our cancellation policy.
Authorization to Disclose Information Form
This form indicates your authorization for use or disclosure of protected health information.
Important: This form is required if you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), and/or if you wish to authorize me to communicate with your insurance company. Please complete this form to authorize release of psychotherapy information.
Note: Adobe Acrobat Reader is required to view these forms. To download Adobe Acrobat Reader for free, click here.
This form indicates your authorization for use or disclosure of protected health information.
Important: This form is required if you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), and/or if you wish to authorize me to communicate with your insurance company. Please complete this form to authorize release of psychotherapy information.
Note: Adobe Acrobat Reader is required to view these forms. To download Adobe Acrobat Reader for free, click here.
