Forms
Before your first appointment, please review and complete the following forms:
Before your first appointment, please review and complete the following forms:
| initial_intake_2021.doc |
Please fill out the Initial Intake Form, as best you can, prior to your first visit. Although it is long, it provides me with important information about you and offers you a chance to give some thought to the specific needs and goals you would like to address.
Thank you.
Thank you.
| outpatient_services_contract_2022.docx |
Please read and sign the Service Contract and bring to your initial consultation. If you have any questions or concerns about any of it, please bring this up during our session together and we can discuss it.
| consent_to_treat_2022.docx |
Please read and sign the Consent To Treat form. If you have any questions or concerns about it, please address this during your appointment.
| hipaa_2021.doc |
This is a copy of HIPAA guidelines regarding confidentiality of your protected health information. These are simply for you to review. There is no need to print these out.
| patient_demo_and_insurance_info_intake_form_2022.doc |
Please fill out the Patient Info form. This includes the no show policy and electronic communications release form. If you have questions or concerns about any of these forms please let me know.
| teletherapy_informed_consent_2020.docx |
Please fill out the Teletherapy Informed Consent form.
Lastly, if you could please fill out this Adverse Childhood Events Survey it would be most helpful.
https://www.ncjfcj.org/sites/default/files/Finding%20Your%20ACE%20Score.pdf
Thank you for your time in filling out these forms. It is greatly appreciated.
https://www.ncjfcj.org/sites/default/files/Finding%20Your%20ACE%20Score.pdf
Thank you for your time in filling out these forms. It is greatly appreciated.
If you are not able to access these forms online or print them please let me know and come to your appointment 20 minutes early and I will leave copies of the forms for you to complete in the waiting room.
I appreciate your taking the time and effort to fill these out. I look forward to meeting with you.
I appreciate your taking the time and effort to fill these out. I look forward to meeting with you.