Switch to Accessible Site

Counseling Services

Individual Therapy
Couples & Family
Assessment
Personal Growth and Wellness
Parenting Support
Stress Management

African American Mother with Daughter
African American Boy

Forms

New Client Paperwork:

If you're a new client, please complete the following forms and bring them to your first therapy session. The below forms serve as a consent for treatment. DO NOT date as we will do this then. Please bring your insurance card and photo ID to your first appointment.

Client Information Form
Consent and Authorizations Form

Technology Consent Form
Privacy Policy Form/HIPPA (Yours to keep)
Medical History Form

Other Forms:  

If you would like us to coordinate care with another provider (for example, your psychiatrist, primary care physician, school personnel etc.), complete this form to authorize the release or receiving of information. (Note: we must have a release of information form on file for EACH individual that you would like us to contact)

Release of Information Form


Confidentiality & Privacy Policy

The law protects the relationship between a client and a therapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependent adult or elder abuse, for which we are required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, we must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, we will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, we will take further measures without their permission that are provided to us by law in order to ensure their safety.

 


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

 

Helpful Forms

Click here to view and print forms for your appointment.

CLICK HERE