Switch to Accessible Site
Helping you fulfill yourPotential
Hands Holding Plant

Forms & Privacy Policy

All forms in each of the following sections are necessary upon the first appointment.

New Client Intake Forms

Information Form
Client Concerns
Checklist of Concerns
Informed Consent
HIPPA
Electronic Payment Forms

Electronic Pay Authorization
Electronic Pay Information

Authorize Release of Information
Please email request for this form

Note: To download Adobe Acrobat Reader for free, click here

Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in insuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.

It is important to note that if you are submitting an insurance claim whether through a provider or you personally have submitted the claim, confidentiality cannot be guaranteed once the information is in the hands of the insurance provider. Insurance providers are able to provide submitted information, including diagnosis, to employers, insurance carriers and other parties. It is important to speak directly to your provider for details.
Click here for a copy of HIPPA regulations.

 

 

 

 

Helpful Forms

Click here to view and print forms for your appointment.

Click Here