Intake Packages Below are in PDF format. Click Link for desired package (Download complete package. There are 3 separate PDF files in the package. Fill out Intake Form, completely read HIPAA Notice & Professional Disclosure Statement and sign Confidentiality Waiver for Electonic Communication. Print and bring all 3 of these to your first session.

Individual Intake Form Package (includes Intake Form, HIPAA & PDS and Electronic Confidentiality Waiver)

Couples' Intake Form Package (includes Intake Form, HIPAA & PDS and Electronic Confidentiality Waiver)

Family Intake Form Package (includes: Intake Form, HIPAA & PDS and Electronic Confidentiality Waiver)

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)