*Available online too; please email us to access online if you didn't receive it prior to your intake
Please fill out the form that applies to you or your child's age and bring them to your first appointment, and any court documents (if applicable). If you have a custody agreement, we must have a copy of this on file prior to seeing your child.
Informed Consent of Policies (3 TOTAL FORMS)
If you are participating in group therapy, please view and sign this consent form for services:
If you would like your therapist to coordinate care with another provider at any point during therapy (i.e,, psychiatrist, physician, other family member, step-parent, etc.), complete this form to authorize release of psychotherapy information:
The law protects the relationship between a client and a therapist, and information cannot be disclosed without written permission.
Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.