Forms
Please ensure that ensure that you have Adobe Reader or a PDF reader installed on your computer to view and print these documents.
Professional Disclosure Statement
Required for all clients to read and understand. It is referenced on the signature page. This does not need to be printed unless you want one for your records.
| Professional Disclosure Statement |
Release/Exchange of Information
This form is necessary if you would like me to/or believe it would be helpful for me to speak with other practitioners (therapists, physicians, teachers, case managers, etc.) and exchange information about the services you are receiving.
| Consent to Release Information |
Intake Paperwork Packets
Choose the packet appropriate to the level of services you are choosing (Individual Adult, Individual Child, Couples, or Family therapy). Please bring this packet with you to your appointment or submit this information by email before the session.
Individual Adult Intake Packet
Required for individual adult clients to be filled out in full and submitted in person at the session or through email.
| Individual Adult Intake Paperwork |
Please also complete this assessment:
| Adult - APA Level 1 Assessment |
Individual Child Intake Packet
Required for individual child clients to be filled out in full and submitted in person at the intake session or through email.
| Child Intake Paperwork |
Please also complete this assessment as parent/guardian of children 6-17:
| Parent-Guardian - APA Level 1 Assessment |
Have your child ages 11-17 complete the following:
| Child 11-17 - APA Level 1 Assessment |
Couples Intake Packet
Required for the initial couples session. Each individual will fill out an intake document and a Dyadic Adjustment Scale. The family info page needs to be filled out by one of you (or together).
| Couples Individual Intake Portion |
| Dyadic Adjustment Scale |
| Couples Intake Family Paperwork |
Family Intake Packet
One of the parents will need to fill out the family intake document. Additionally, each individual participating in counseling will need to sign a Signature Page.
| Family Intake Paperwork |
| Signature Page |