To be prepared for your first visit with us, please see below.
Section One: Print, complete (select either Adult or Child), and bring to your first appointment:
Section Two: Reference/Read Only and/or Save/Print for your records:
- Consent for Treatment/Limits of Liability
- HIPPA - Consent for Use and Disclosure of Health Information
- Patient Rights & Cancellation Policy
If you would like to participate in Telemental Health sessions, please complete the following form (PDF version) or complete the following instructions (Online/E-Sign version):
- Click Link- https://form.jotform.com/200845895672063
- Click - Green Box “Start Filling —>”
- Complete All Fields, Including Signatures
- Click- Green Box “Submit”
- Click - Blue Box “Send PDF as Email”
- Enter email: “[email protected]” and click Blue Box “Send”
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete the form in PDF or Online E-Sign to authorize release of psychotherapy information:
Authorization for Release of Information Online Form Instructions:
- Click Link- https://form.jotform.com/200905065703044
- Click - Green Box “Start Filling —>”
- Complete All Fields, Including Signatures
- Click- Green Box “Submit”
- Click - Blue Box “Send PDF as Email”
- Enter email: “[email protected]” and click Blue Box “Send”
Additional Forms (Print As Needed)
- Adult Psychotherapy Intake Form (18+)
- Child Psychotherapy Intake Form (Under 18)
- Child Psychotherapy Intake Form Cover Sheet (Under 18)
- Informed Consent
- Patient Care Communication Form
- Treatment Plan Acknowledgement Form
- Payment Acknowledgement Agreement Form
- Privacy and Rights Acknowledgement Form
- Health Risk Assessment (Adults Only Ages 18+)
- Health Risk Assessment (Child Only Ages 0-17)
Note: To download Adobe Acrobat Reader for free, click here.