Forms

Consent for Services for Adult Clients(Ages 18 +)
If you are over age 18, please print out this form, read it carefully, sign it, and bring it to your first appointment. You should also keep an additional copy for your records.

Parental Consent for Services for Adolescent Clients(Ages 13 – 17)
If you are the parent of an adolescent client between the ages of 13-17, please print this form, read it carefully, sign it, and bring it to your child’s first appointment. You should also keep an additional copy for your records. In addition, your child should complete the Adolescent Assent for Services form below and bring it to the first appointment.

Adolescent Assent for Services(Ages 13 – 17)
If you are a client between the ages of 13 - 17, please print out this form, read it carefully, sign it, and bring it to your first appointment. You should also keep an additional copy for your records. Your parent or guardian should complete the Parental Consent for Services for Adolescent Clients form above and bring it to the first appointment.

Parental Consent for Services for Child Clients(Under age 13)
If you are the parent of a child client under age 13, please print out this form, read it carefully, sign it, and bring it to your child’s first appointment. You should also keep an additional copy for your records.

HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) is a federal mandate for privacy issues that cover certain health services. Clients over age 18 and parents of child and adolescent clients are advised to read this form prior to their first appointment. You should also print out a copy of this form for your records.

Client History Form
All clients over age 18 should complete this form. You may complete this form on your computer, then print it out and bring it to your first session.

Parent Questionnaire
Parents of child and adolescent clients under age 18 should complete this form. You may complete this form on your computer, then print it out and bring it to your child’s first session.

Electronic Payment Authorization Form
To save time and eliminate the hassle of weekly payment, I strongly encourage clients to complete the Electronic Payment Authorization Form. This form allows me to deduct the session fee (including fees for no-shows and late cancellations) from the credit card or debit card designated on this form. Please print out this form, complete it, and bring it to the initial appointment. This information will be stored securely in your clinical file and may be updated upon request at any time.

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