Forms

Please download, print, and complete the appropriate set of forms
and bring them to our first meeting.  
Legal and ethical guidelines prevent me from providing any services
without these completed forms.
Thanks for your understanding.
  

New therapy clients should complete the forms in purple.

DOT-SAP clients should complete the forms in black.

All clients should read the HIPAA information and return only the completed signature page.

Please contact me before our scheduled initial appointment if you have any questions about these forms.





Forms for new therapy clients
(each form will open in a new window)

Only for clients using in-network insurance benefits



Please fill in either the session rate we agreed upon or your co-pay per visit


 
Release of information (optional)
Please complete the release form if you want me to contact your physician, previous therapist, or anyone else



Forms for DOT-SAP clients
(each form will open in a new window)

Please enter your DER's contact information