Client Forms

For new clients, please complete the following Intake Form as well as the Disclosure Statement and Consent for Services form.  You may fill them out directly on this page or if you prefer, download and print out the pdf versions then bring them to your first therapy session.

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please also complete the Authorization to Disclose Information Form.

Please also CLICK HERE to read our Notice of Privacy Practices

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Download and print this form by clicking the following button:

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client forms

Intake Form

All fields are required.  Put n/a in any field that does not pertain to you.

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.
*Please note: Email correspondence is not considered to be a confidential medium of communication.
*Please note, not all insurance is accepted. Coverage and payment amount must be confirmed prior to your first session.
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
FAMILY MENTAL HEALTH HISTORY:
ADDITIONAL INFORMATION: