All documents below are in PDF format. Click Links in the category that applies to you. Fill out Intake Form, completely read HIPAA Notice & Professional Disclosure Statement and sign Confidentiality Waiver for Electonic Communication. If you click on the "Submit by Email" button at the top of the intake form, please also bring a printed version as some email applications are not compatible with the automatic email function.
If you are a new Individual Client, Please click on and print the 4 items below. Fill out the Individual Intake Form and Electronic Communication Addendum and bring to your first Appointment:
1. Individual Intake Form
2. HIPAA Notice of Privacy
3. Professional Disclosure Statement
4. Electronic Communication Confidentiality Addendum
If you are a new Couple Client, Please click on and print the 4 items below. Fill out the Individual Intake Form and Electronic Communication Addendum and bring to your first Appointment:
1. Couples' Intake Form
2. HIPAA Notice of Privacy
3. Professional Disclosure Statement
4. Electronic Communication Confidentiality Addendum
If you are a new Family Client, Please click on and print the 4 items below. Fill out the Individual Intake Form and Electronic Communication Addendum and bring to your first Appointment:
1. Family Intake Form
2. HIPAA Notice of Privacy
3. Professional Disclosure Statement
4. Electronic Communication Confidentiality Addendum
If you are a new Child/Adolescent (Legal Guardian) Client, Please click on and print the 4 Items contained in the package. Fill out the Intake Form and Electronic Communication Addendum and bring to your first appointment:
Child/Adolescent Intake Form Package (includes: Intake Form, HIPAA & PDS and Electronic Confidentiality Waiver)
Other Forms:
Credit Card Authorization for Payment (Electronically Fillable Form)
Release of Information Form (PDF)
Health Insurance Claim Form (PDF) Print this form, fill out the upper section with your personal and insurance information and return to me so that I can fill out the lower section. This will allow you to get reimbursed for your visits from your health insurance company. It is your responsibility to check with your insurance company before your first visit to verify your reimbursement eligibility.
Professional Disclosure Statement (PDF)
Confidentiality Waiver for Electronic Communication (PDF)
HIPAA Notice of Privacy Practices (PDF)
