In preparation for your appointment with us, we have provided links to our intake forms for your convenience. These forms can also be completed via our patient portal. Please contact our office for a link if you have not received one.
If not completing through our portal, please click on the links below, complete the forms online and email to us at firstname.lastname@example.org or print the completed form 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 email prior to or 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,we ask that each person 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. We ask that you sign the back page and return to us. Please retain the information pages for your reference.
Only the primary guardian(s) can sign on behalf of a child. Additionally, if it pertains to your situation, (such as divorced parents, etc) we will need a copy of the medical rights portion of the court document indicating who has rights to your child’s records. Please send this along with your intake documents.
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 enter the appropriate number that corresponds to how often you experience the particular symptom. Once complete, this form can be emailed with the other items in your intake packet or emailed to us.
In the event of couples or family counseling, we ask that all members of the family 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 enter 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.
If the client is a child of divorced parents, we ask that all parents complete this form.
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.
Only legal guardians can sign on behalf of a child.
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.
Review this form when you are preparing for Telebehavioral Health services with your provider.