Helpful Forms

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
• Payment Policy Form
• Practice Policies and Procedures
• CLIENT INSURANCE FORM
• Agreement for Telehealth Services

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:

• Authorization to Disclose Information Form

 I AM NOT A MEDICARE PROVIDER. If you choose to work with me, you agree to be responsible for full payment of my services.  I am unable to submit claims to Medicare. 
IF YOU ARE 64 OR OLDER, PLEASE COMPLETE AND SEND ME THIS FORM:

• Medicare Eligible Client Responsibility
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