Forms

Once you have scheduled an intake evaluation appointment, please print out and complete the following forms and bring them to your first session. Please complete the forms as accurately as possible. If you withhold or omit information on the forms or during your intake evaluation, it may become necessary to refer you to another therapist or agency if that information significantly impacts treatment.

All forms are in PDF format. You will need to print each form individually. If you do not have Adobe Acrobat Reader on your computer, you may download it here.

Intake Form
Psychological Services Agreement
Office Financial Policy
Statement Regarding Treatment Populations
Symptom Checklist
Psychosocial History
Medical History
Telepsychology Informed Consent Form

Please also review the following documents; you may print a copy for your convenience:

Notice of Privacy Practices (HIPAA)
Protocol for the Secure Storage, Transfer, and Access to Client Records
Social Media And Electronic Communication Form
Request for records (to have your records forwarded to another provider)
Release of information form (to give permission to contact another provider)

Counseling and Psychological Services

Forms

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