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Forms

Prior to our first session, please complete this form. This will help you share important details with me that you might have otherwise forgotten, and help our first meeting to occur more comfortably.

Please click the links below to read and acknowledge the following forms:

Informed Consent
This form not only reiterates the important information we touched on in the consultation about confidentiality in more detail, it also explains my office policies and agreement to services. If you have questions, we can go over them in our first session so that you have a clear understanding about what you are reading.

HIPPA
I am required by law to provide you with a copy of the HIPAA Notice of Privacy Practices so you can understand your rights and protections related to the use and disclosure of your identifiable health care information.

Social Media Policy
This explains my policies as they relate to possible interactions on the internet. Please let me know if you have questions, concerns, or issues.

Non-Violent Communication

 I have read and understand the Informed Consent, HIPPA, Social Media Policy, and Non-Violent Communication form. (required)

Legal Name (required)

Preferred Name (if different)

Email (required)

May we email you?

Street Address

OK to Send Mail?

Emergency Contact (please include phone number and relationship)

What Level Of Confidentiality Do You Prefer With Each?

Date of Birth / Place
/

Age

Phone

Secondary Phone

May we call?

May we leave a voicemail?

Demographic Info

Gender

Sexual Orientation

Relationship Status

Ethnicity

Occupation/Employer

Receipt Information

Will You Be Requesting A Bill?

Is it for insurance or for a flex spending plan?

Referral Information

Current Reason(s) for Seeking Therapy

Severity
 Mild Moderate Severe Very Severe

How Did You Hear About Me?

Have You Previously Been In Psychotherapy?

When and for What Reasons? Was it Helpful?

Do you have any previous suicide attempts, self destructive behaviors, or violent behaviors? (Indicate age, circumstances, and whether it led to hospitalization or legal problems).

Please list any past/present drug and alcohol use. What have you used and how
much? What are you currently using and how much?

Relationships

Do you live with others? What is their relationship to you?

Present Spouse/Partner(s) (first name(s), occupation(s), how would you describe
your relationship satisfaction?)

Are there any other current relationships that are a significant focus in your life right now? Please describe:

Other

What are your worries/fears?:

What are your main strengths?:

What are your challenges?:

What are your most important hopes or dreams? :

Please add any additional information that may be helpful to our work together.:

Do you have specific goals for therapy at this time? Tangible results that would
help you feel like your work has been a success? Or is part of the work you want
to do discovering that very material. :

 

Once you have read my Informed Consent and my Social Media Policy, and filled out the form above, please download, print and sign this form and bring it with you to the first session: Acknowledgement of Notifications

This states that you have access to and have read and understood all forms. If you are having trouble accessing a computer and/or printer, please speak to me about this at least 48 hours before our first appointment and I will make arrangements.