New Clients: . please complete the following forms and bring them to your first counseling session
IF YOU ARE SCHEDULING A COUPLES OR FAMILY THERAPY APPOINTMENT, PLEASE HAVE EACH PERSON READ AND SIGN THE "PRACTICE POLICIES & PROCEDURES" FORM, AND HAVE EACH PERSON FILL OUT A SEPARATE CLIENT INTAKE FORM.
Only the person responsible for payment needs to complete the Payment Policy Form.
Only the person who will be filing an insurance claim as the "identified patient" needs to complete the Client Insurance Form.
- Client Intake Form
- /userfiles/4717295/file/Payment Policy Form(3)-5(2).pdf
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of treatment information:
If you are 65 or about to turn 65, you need to opt out of using your Medicare benefits for mental health services since I AM NOT A MEDICARE PROVIDER.
Please fill out this form:
- userfiles/4717295/file/Medicare Eligible Client Responsibility.doc
- Note: To download Adobe Acrobat Reader for free, click here.