New Client Forms

P lease complete the following forms and bring them to your first therapy session.

Client Psychotherapy Intake Form

Limits of Confidentiality/Therapy Cancellation Policy

Long Intake Form Telepsychology Informed Consent Form

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information: Authorization to Disclose Information Form.

Authorization to Disclose Information Form

For Hypnosis Clients please read and sign

Hypnosis Consent Form

For 65 year old clients and older to print out, sign, date and submit with their PPO Insurance request  (Medicare)

Medicare Opt-out Letter for Clients

Medicare/Medicaid Opt-Out Affidavit

Medicare Opt-out Letter

Medicare Opt-out Affidavit

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