New Client Forms
Before arriving for your first appointment…
You will want to complete the appropriate forms on this page.
Please print, complete and bring them to your first appointment. If you are unable to complete the forms, please arrive at least 20 minutes early for your initial appointment so you can complete the forms at my office.
All clients (18 years or older) must review and complete the following four forms:
Client Registration Form
Outpatient Services Contract
Communications Policy
Adult Client Information Form
If the client is younger than 18 years, please complete:
If the client is younger than 18 years, a parent/guardian should complete:
In addition to reviewing and/ or completing the above three forms: Client Registration Form, Outpatient Services Contract & Communications Policy
If an authorization for release of confidential information is needed, an adult client or a parent/guardian should complete:
Authorization for Release of Confidential Information
Notice of Privacy Practices
No Surprises Act 2022
(Notification Required by Federal Law)
Beginning January 1, 2022, the “No Surprises Act” is a federal law that requires health care providers to provide new and established patients who don’t have insurance or who are not using insurance, or patients who are shopping for care, a good faith estimate (GFE) of costs for services that they provide. You have the right to receive a "Good Faith Estimate" explaining what the charges could be for psychotherapy services provided to you.
I will offer information about the cost of psychotherapy orally in an initial intake phone call or written via email when therapy is first discussed and scheduled or when potential new clients inquire about scheduling and/ or costs. I also will provide a separate written document detailing the cost of therapy. You have the right to ask about costs of treatment, length of treatment and any other questions that arise about your therapy and our process together.