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Patient Forms

These forms can be completed online before printing, signing, and presenting at the initial appointment.

Intake Form Healthcare Information

Welcome to my practice. I look forward to helping you accomplish your counseling goals. The information will help me to better understand your situation and suggest potential solutions for helping you get your life back on track. Please note: This information is confidential, for my use only, and will not be released to anyone without your written permission – unless I believe there is a danger of injury to you or another person.

HIPAA Disclosure Notice

The Health Insurance Portability and Accountability Act of 1996 is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996.

Insurance Form

Insurance Form must be filled out so that we may be able to bill your insurance for your sessions.

Consent to Release Healthcare Information

This form is mandatory and kept in your file in the event that you would or would not want your records sent to anyone outside of this office.