Licensed Professional counselor
Certified DOT-SAP PRovider

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

  c   610.416.0793
  f  610. 566.3274  ​​

 new therapy client forms and information



Please complete the relevant intake and
the forms linked below. Please fax, scan, or email me the completed intake form
at least 2 business days before our first scheduled appointment.
Please bring the other completed forms to our first meeting.

Please allow 1.5 -2 hours for our first meetings

Subsequent therapy sessions are 1 hour 

(we can schedule longer sessions as needed)

Please read the HIPAA information but return only the signature page.  Thank you!

each form will open in a new window

Assignation of benefits
Only for those using Highmark insurance

Please enter 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
fax/scan/email me the completed intake form 
at least 48 business hours before our first appointment and 

bring the other completed forms when we meet.

Thank you! 


I have a 24-hour cancelllation policy.

Please provide at least 24- hours' notice to
reschedule an appointment. If you must reschedule
a Monday appointment, please
contact me by 5p on the preceding Friday.

Thank you for your consideration.

Insurance does not pay for late cancellations or missed appointments.

Insured clients are charged $75 for missed initial evaluations
or those cancelled with less than 24-hours' notice and
$50 for missed one hour therapy sessions or those cancelled with less than 24-hours' notice

Self-pay clients are charged  $100 for missed
initial evaluations or those cancelled with less than 24-hours' notice and
our agreed upon hourly rate  
for missed one hour therapy sessions or those cancelled
with less than 24-hours' notice.

I appreciate your understanding.


Please feel free to contact me with ​​
any questions about these forms or
anything else.

Ethical and legal guidelines prohibit me from
meeting with new clients without these  completed forms. 

Thank you for your cooperation.