Intake Forms

Please review all appropriate forms and bring them to your first initial session. Please print,  fill them out to the best of your ability. I am happy to answer any questions or concerns pertaining to these forms at the initial session.

**Please note, if you are interested in your child engaging in therapy, you will need to provide documentation of custody, i.e., joint, sole, guardianship, etc.

 Adult Intake                                   Adult Informed Consent

Minor Intake                                   Consent toTreat Minors

Minor Informed Consent

Couples Informed Consent              Couples Intake

Couples Agreement

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Confidentiality & Privacy

I will carefully guard and maintain your right to confidentiality. Information will not be disclosed without your written permission. Although confidentiality and privileged communication remains the rights of the client, state and local laws hold the therapist responsible to report to the appropriate authorities the following exceptions:

All cases of suspected child abuse, incest and molestation. Suspected elder abuse and/or dependent adult abuse. If an individual communicates an intent to harm him/herself or someone else, it is the therapist’s duty to warn/protect the person(s) involved.  If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.

**Note:  If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring 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.

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