Forms

During your first session, there are several forms that will need to be completed. You may download the forms below, complete them, and bring them with you to your appointment. Or you can complete them in the office. Please do not email forms as they contain confidential information and email is not considered secure. We are happy to answer any questions you may have about these documents.

Service Agreement: This form tells you about how we can work together, and about my policies and practices.

Notice of Privacy Practices: This form tells you specifically about my privacy policies, confidentiality, and the legal limitations of confidentiality.

Client Rights and Responsibilities: This form explains your rights and responsibilities related to counseling services.

Intake Form:  This form tells me about you and why you are considering counseling at this time. Please complete as much information as possible; however, feel free to skip over items that are not applicable to your circumstance.

Client Symptom Checklist: This is a checklist of reasons why people seek counseling and has a rating scale where 1  = never, and 5 = often.

Insurance Information and Authorization: This form contains your insurance information and gives permission to bill your insurance company.

Primary Care Physician:  This form tells me whether or not you want information sent to your Primary Care Physician. Some clients want me to provide brief periodic updates to their physicians, others do not. Releasing this information to physicians is optional, and this form indicates your choice.

Depending upon your insurance plan, there may be additional forms to complete during our first session and/or on a regular basis.