CLIENT FORMS AND INSTRUCTIONS

INSTRUCTIONS FOR COMPLETING FORMS

Here are all the client forms you will need to get you started. You can print out these forms, complete them by hand, and bring them to your first session with your therapist who will review and cosign them with you.

IMPORTANT: do not fax or email these forms, in order to ensure that your privacy is protected.

Downloadable Forms

Instructions For Completing Intake Packet

Client Information Sheet

  1. Fill in all sections with your personal and insurance information.
  2. Clients under 18 years of age must have their parent or guardian write in their names.
  3. At the bottom, write down your reason for seeking psychotherapy, if you’ve had treatment before, and if so, your prior therapist’s name, location, and phone number.

Authorization to Disclose Protected Health Information

  1. Top Section: fill in your personal information
  2. Check off if you are the person seeking treatment or a representative.
  3. List your contacts in the spaces provided. NOTE:
    1. You must list an emergency contact, their relationship to you, and their contact number
    2. You must list your primary care physician as well as any other specialty physicians who may be treating you.
    3. You must list your health insurance plan or EAP, if you have one.
    4. Leave the Signature lines blank until you meet with your therapist.

Consent for Use of Personal Health Information

  1. Read carefully
  2. Leave the Signature lines blank until you meet with your therapist.

For Your Information

  1. Read carefully
  2. Leave the Signature lines blank until you meet with your therapist.

Litigation Disclaimer

  1. Read carefully
  2. Leave the Signature lines blank until you meet with your therapist.

Client Safety Certification

  1. Read carefully
  2. Only complete the appointment information in the middle of the form, if you have a pending appointment with another provider for a psychological or psychiatric evaluation.
  3. Leave the Signature lines blank until you meet with your therapist.

Health Insurance Claim Form

  1. Complete only the top section, Items 1 through 13.
  2. Leave the Signature lines just below Items 12 and 13 blank until you meet with your therapist.