Forms

Starting our Work Together: Client Information Brochure

This form explains how I approach therapy, reviews the nuts and bolts of how my practice works, details our mutual responsibilities, and serves as an informed consent for treatment. It would be helpful to read this by our first meeting.

Client Information 1: Intake

This form needs to be filled out by our first meeting. It is a brief intake form asking for basic demographic information.

Notice of Privacy Practices

This form describes the privacy regulations that govern how medical and health information may be used and disclosed. This form is in two parts: The first part is a simplified, abridged version, and the second part is the longer, unabridged version. By law, you must review the NPP by our first meeting.

Consent to Privacy Practices

This form is a consent form to the privacy practices. It too must be signed by our first meeting.

Client Information 2: Demographic Information

This form needs to be filled out by our second meeting.

Client Information 3: Clinical Information

This form needs to be filled out by our second meeting.

Client Information 4: Health Information

This form needs to be filled out by our second meeting.

Client Information 5: Credit Card Authorization

This forms needs to be filled out if you choose to use your credit card for payment.