Licensed Professional counselor
Certified DOT-SAP PRovider

​​​​ 780 East Market  Street #280
 West Chester, PA 19382

  c   610.416.0793
  f  610. 566.3274  ​​

Forms for new therapy and DOT-SAP clients

New therapy clients:
please complete the 
adult intake form  or adolescent intake form and
return it to me via email/fax at least 2 business days before 
our initial appontment.
Additionally, please complete the set of purple 
forms linked below and bring them to our first meeting 



New therapy clients should complete the relevant intake and
7 forms liked below in purple.

New DOT-SAP clients do not need to complete an intake
form but should complete the
5 forms linked below in blue.

All new clients should read the HIPAA information but  return only the signature page.

Forms for new therapy clients
Each form will open in a new window

Assignation of benefits
Only for those using Highmark insurance

Please enter the your co-pay or the session fee we agreed upon

Please return only the signature page 

Please complete this if you'd like me to speak with your attorney, physician, previous therapist (or anyone else)

Please remember to
complete and return the intake form above via fax or email
at least 48 business hours before our first appointment (and

bring the other completed forms when we meet).
Email: amyebrown.lpc@gmail.com    

Thank you for your cooperation!

​Forms for DOT-SAP clients:
Each form will open in a new window

Please enter your DER's contact information

Please return only t he signature page -keep a copy for your records if you like

Please contact me with any questions about forms or
anything else related to the first appointment.

Ethical and legal guidelines prohibit me from
meeting with new clients without the requested completed forms. 
Thank you for your cooperation.