INTAKE FORM: If you want to become a new patient, complete the following form to start the intake process. Completing this form DOES NOT guarantee that you will be accepted as a patient in our clinic. It is simply the first step of the intake process. Be sure to respond to ALL questions. One of our staff members will contact you, usually within a week of receiving the completed form.
Electronic: Initial Intake Form -OR- Print: Initial Intake Form
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NEW PATIENT FORMS: If you have been accepted as a new patient:
Complete and sign the following forms prior to your first visit. If
the primary focus of the service is for a child/youth
under 19 years of age, please entirely complete all
"Child Forms." If the primary services will be provided to someone
19 or older, please entirely complete all "Adult
Forms." If you are a patient returning to clinic after a year or
more, please complete all "Update Forms."
Forms for Child Patient: Forms for Adult Patient: Forms for Returning Patient:
Electronic: Child Paperwork Electronic: Adult Paperwork Electronic: Paperwork
Electronic: Family Inventory Electronic: Family Inventory
- OR - Print the forms below, complete and sign, and bring them with you to your first visit.
Print: Child Forms Print: Adult Forms Print: Update Forms
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TELEHEALTH FORMS: Complete BOTH of the following consent forms before engaging in telehealth therapy:
Electronic: Telehealth Informed Consent -OR- Print: Telehealth Informed Consent
Electronic: Email and Text Consent -OR- Print: E-Mail and Text Consent
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IN-PERSON FORM: Compete this form before engaging in in-person therapy:
Electronic: In-Person Consent -OR- Print: In-Person Consent
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RELEASE FORM: Complete this form to authorize release of psychotherapy information to/from other persons:
Electronic: Release of Information -OR- Print: Release of Information
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DIVORCE CONSENT: If parents/guardians are separated or divorced, the Agreement for Child Psychotherapy with Separated or Divorced Parents/Guardians is to be signed by both parents/guardians:
Electronic: Divorced Parents Agreement -OR- Print: Divorced Parents Agreement
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ASSESSMENT AUTHORIZATION: Complete this form to authorize psychological testing/assessments:
Electronic: Authorization for Assessment -OR- Print: Authorization for Assessment
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PRIVACY NOTICE: The Notice of Privacy Practices describes how psychological and medical information about you/your child may be used and disclosed:
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HANDOUTS: Helpful guidelines:
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