Once you have scheduled an initial appointment with me, please download and print the first three forms below (Intake Information, Disclosure Statement, Client Responsibilities and Fees), fill them out and sign them, and bring them with you to our first session (or you may mail or email them).
If you will be doing telehealth sessions, please download and print the fourth form, Telehealth Informed Consent, and sign and return the form.
If you wish to pay via credit or debit card, please download and print the fifth form, Credit or Debit Card Processing, and sign and return the form. You may also pay by check.
Please also bring your health insurance card to our first session. Or, you may send a copy, front and back, of your card prior to our first session. If you are certain that your health insurance requires only a copayment, you may pay that amount up front. Otherwise, you are responsible to pay the insurance’s allowed amount per session, or my regular fee per session if you do not have or wish to use insurance.
The sixth form, HIPAA Notice of Privacy Practices, is for your information only and does not need to be printed.
The seventh form, Authorization for Release of Information, may be used if it would be useful for me to coordinate care with another treatment provider, and/or if it would be helpful in your treatment that I have information from a previous counselor or treatment provider.
Intake Information
Click to download. Complete this form after you have set up an initial appointment with me.
Disclosure Statement
Click to download. You will need to complete this form as well prior to our appointment.
Client Responsibilities and Fees
Click to download. This also needs to be completed and brought to our first appointment.
Telehealth Informed Consent
If doing telehealth, click to download. Sign and return this form.
Credit or Debit Card Processing
If paying via credit or debit card, click to download. Sign and return this form.
HIPAA Notice of Privacy Practices
You can click to download and read this form, but it does not need to be printed.
Authorization for Release of Information
If you want information shared with another provider, click to download and fill out this form.