Documents

NEW CLIENTS: INDIVIDUAL ADULTS

Please review and complete the following paperwork and bring it with you to your first appointment.

New Client Information(FOR ADULTS ONLY) This form collects necessary office-related information as well as a detailed personal and mental health history. Please complete this form and bring it with you to your first appointment.

Disclosure Statement Stanford   The board that governs my licensure requires that clients have access to information about my qualifications as a therapist. Please review this disclosure and bring a signed copy to your first appointment.

Treatment Agreement This document outlines my business policies and includes financial information. Please review it and bring a signed copy to your first appointment.

Client Health Information Rights Please review this document that outlines your rights regarding the transmission of personal health information.

Unprofessional Conduct Please review this document that defines unprofessional conduct and provides instructions for anonymously reporting any unprofessional conduct to the appropriate governing body.

NEW CLIENTS: COUPLES 

New Couple Information Please complete one of these and bring it with you to our first appointment

Disclosure Statement Stanford   The board that governs my licensure requires that clients have access to information about my qualifications as a therapist. Please review this disclosure and bring a signed copy to your first appointment.

Treatment Agreement This document outlines my business policies and includes financial information. Please review it and bring a signed copy to your first appointment.

Client Health Information Rights Please review this document that outlines your rights regarding the transmission of personal health information.

Unprofessional Conduct Please review this document that defines unprofessional conduct and provides instructions for anonymously reporting any unprofessional conduct to the appropriate governing body.

NEW CLIENTS:ADOLESCENTS 

Please review and complete the following paperwork and bring it with you to your first appointment.

Parent/Guardian Adolescent Intake Form(FOR PARENTS/GUARDIANS OF ADOLESCENTS ONLY). This form is for parents or guardians of adolescents to  complete and collects necessary office-related information as well as a detailed personal and mental health history about your child.

New Adolescent Client Information(FOR CLIENTS UNDER 18 ONLY). This form collects personal information before our first appoint. This information will not be shared with your parent or guardian unless it puts you at immediate risk (see Adolescent Informed Consent Form for more information).

Adolescent Informed ConsentIf you are an adolescent or a parent or guardian of an adolescent, please review this document that outlines confidentiality considerations with minors.

Disclosure Statement Stanford   The board that governs my licensure requires that clients have access to information about my qualifications as a therapist. Please review this disclosure and bring a signed copy to your first appointment.

Treatment Agreement This document outlines my business policies and includes financial information. Please review it and bring a signed copy to your first appointment.

Client Health Information Rights Please review this document that outlines your rights regarding the transmission of personal health information.

Unprofessional Conduct Please review this document that defines unprofessional conduct and provides instructions for anonymously reporting any unprofessional conduct to the appropriate governing body.

ADDITIONAL FORMS

Release of Information If you would like me to speak to someone about your treatment you must fill out this form and return it to me.

Credit Card Information If you did not include any credit card information upon intake and would like me to start charging a card for services, please complete and sign this form and return it to me.

Telehealth Informed Consent If we have agreed to engage in Telehealth Services, please review and sign the following form and return it to me.