Initial Intake Form

 

If you're a new client, please print out and complete the Intake Form and bring it with you to your first therapy session.

 

• Initial Intake Form  (click here)

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Additional Forms 

 

These forms are listed for your reference, the Informed Consent Form will be completed during your first appointment. (click below to open PDF)

 

• Informed Consent Form/Agreement for Service

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• Minor - Informed Consent Form/Agreement for Service

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• Therapy is Confidential Information

 

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize the release of psychotherapy information: 

 

• Authorization to Disclose Information Form - HIPAA Information Form

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Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission. 

 

Exceptions include:

• Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.

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• If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim. 

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• If a client intends to harm him or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.