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/203545780388060
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  

 

 

Additional Forms- 

2021 INFORMED CONSENT FOR TELEMENTAL HEALTH TREATMENT Form

If you would like to participate in Telemental Health sessions in 2021, 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/203493558390159
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

 

Informed Consent & Health Risk Assessment (Adult 18+) Combo E-Sign Form:

1. Click Link- https://hipaa.jotform.com/203455452788060
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

 

Informed Consent & Health Risk Assessment (CHILD 0-17) Combo E-Sign Form:

1. Click Link- https://hipaa.jotform.com/203455910288054
2. Click - Green Box “Start Filling —>”
3. Complete All Fields, Including Signatures
4. Click- Green Box “Submit”

 

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:

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”

 

 

**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”

 

 

 

PDF's of 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)
• Therapist Acknowledgement Form

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