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Online Forms

Intake Forms

In preparation for your appointment with us, we have provided links to our intake forms for your convenience. Please click on the links below, print and fill out the appropriate forms, and bring them with you to your appointment:

Please complete this form if you are a new client or if you have a change in demographic or insurance information.

This form should be completed prior to your initial appointment. Please complete this form for the person who will be receiving services and bring with you to your first appointment. For children, please have the parent or guardian complete this form on his/her behalf. For couples or families, the person who will be identified as the client for billing purposes will need to complete this form.

Our Policy statement contains important information about treatment, confidentiality, and office policy. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). Please read it carefully and if you have questions, your therapist will discuss them with you.

This form is part of the intake packet. Please complete if an adult is the client and bring with you to your first appointment. It lists many symptoms an individual can experience. Please circle the appropriate number that corresponds to how often you experience the particular symptom.

In the event of couples or family counseling, all members of the family are welcome to complete this form to give us information about what each may be experiencing.

This form is part of the intake packet. Please complete if the client is a child or teen and bring with you to your first appointment. It lists many symptoms a child can experience or display. Please circle the appropriate number that corresponds with how often the child experiences or displays the particular symptom. If the child is able to understand the questions asked on the form, he/she may complete this form themselves. However, we would like parent(s)/guardian(s) to complete one as well.

Additionally, if the client is a child of divorced parents, we will need a copy of the “medical rights” portion of the divorce decree.

Other Forms

Complete this form when it is necessary to have your therapist contact someone or obtain records to facilitate your treatment. This fully completed written request must be in place before any information can be forwarded or obtained.

Complete this form when it is necessary to have your sessions or contact with your therapist done via electronic mediums.  A signed copy of this agreement must be in place before any sessions can be conducted in this manner.

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MISSION

Our mission since 1990, we have sought to provide safe, non-judgmental guidance to help our clients find personal growth and freedom from the emotional pain they are experiencing.

VISION

To provide individuals, couples, and families with top quality ethical counseling services.

OUR GOAL

It’s our goal to create a comfortable, compassionate environment where we’ll work together to achieve your success.