New Client Forms
If you are a new client, please print these forms, complete them, and bring them to your first therapy session. Please do not email your personal information. Email is not a private form of communication. If you have questions or concerns about any of these forms, then please talk to me to address your concerns prior to signing anything.  All documents are in PDF format.

 

 
 
Release of Protected Health Information

In order for me to release protected health information in any way, the law requires that you specify the entity/person with whom I will be sharing information, what kind of information I will be sharing, and for what period of time you allow me to share information. Reasons why clients request that information be shared include:

  1. To coordinate care with another provider (for example: your psychiatrist, primary care physician, etc.)

  2. To consult with a trusted family member regarding your treatment

  3. To allow me to complete required reporting to an agency or court who is mandating treatment

  4. To allow me to coordinate payment with a family member or someone else. 


 

If you would like me to be able to share protected health information for these or other reasons, then please complete this form to authorize the release of that information:
 

 


 

Note: You may download Adobe Acrobat Reader for free, click here