Forms

Initial Paperwork to complete

For your convenience, I have added the initial intake paperwork and forms here (for individual adults and couples therapy) so that you may download, print, and complete them at your convenience and prior to our first appointment.

(To view these forms, you will need Adobe Acrobat Reader.  This free software is available from the Adobe Acrobat site.)

Please do read these in advance, and if able please bring the completed forms to your first individual or couple’s appointment with me:

• Client Information
• Informed Consent
• Acknowledgement of receipt of privacy notice
• Notice of Privacy–HIPAA (no need to print this, but this is for your information)

Teletherapy

If you are considering requesting teletherapy services (video-conference using HIPAA-compliant Doxy.me web portal), let’s talk first to see if this would be appropriate for your needs. If we deem it appropriate, please read and complete this form:

• teletherapy informed consent

Release of Information Authorization 

If your insurance is asking for additional information from me, or if we agree that it would be beneficial for me to exchange information with or obtain additional information from another person (e.g., your physician, your former therapist) to best facilitate your progress, please complete this form:

• ROI authorization form

 

For more information or for an appointment, please call me at 408-828-8375 or send me an email.

 

 

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