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: 

• Adult (18+) Intake Packet
• Child (0-17) Intake Packet

 

Or you may complete the Online E-Sign Adult or Child Intake  

Adult (18+) Intake Online Form Instructions:

1. Click Link- https://hipaa.jotform.com/200847603735052
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

Child (0-17) Intake Online Form Instructions:

1. Click Link- https://hipaa.jotform.com/201055942642047
2. Click - Green Box "Start Filling —>"
3. Complete All Fields, Including Signatures
4. Click- Green Box "Submit"

 

 

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):

• Informed Consent for Telemental Health Treatment  (PDF)

 

1. Click Link- https://hipaa.jotform.com/200845895672063
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

If you are returning to in-person sessions, please complete the following form -- 

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

1. Click Link- https://hipaa.jotform.com/201496828644061
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

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 to Disclose Information Form (PDF)

 

Authorization for Release of Information Online Form Instructions:

1. Click Link- https://hipaa.jotform.com/200905065703044
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

 

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.