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Helpful Forms

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: 

 

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:

 

Additional Forms- 

 

INFORMED CONSENT FOR TELEMENTAL HEALTH TREATMENT Form

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):

 

  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 Online Form

  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:

 

 

THERAPIST ACKNOWLEDGEMENT FORM  Online Form Instructions:

  1. Click Link- https://hipaa.jotform.com/202103963178049
  2. Click - Green Box “Start Filling —>”
  3. Complete All Fields, Including Signatures
  4. Click- Green Box “Submit”

 

 

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”

 

 

PDF's of Additional Forms (Print As Needed)


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

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Helpful Forms

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