Initial Session Forms

In-Office Sessions:

If you're a first-time client, please print, fill-out, sign and date the first 4 PDF forms and bring them to your first session. As well, print and read over the last 2 documents and return with your completed forms.

*Please note that even if you are not intending to pay by credit card, I ask that you fill out the credit card authorization.  This authorization remains on file if you no-show for your scheduled appointment,  do not give a 24 hour cancelation notice or if a session is conducted by phone or remotely.

Holding Your Scheduled Session Slot:

As a first-time client, I ask that you make a one time payment online to hold your session slot no later then 48 hours before your scheduled appointment. Please go to the "Make A Payment" page on this site.  Use the drop-down menu to select the payment fee we had previously discussed.  

This payment will be applied to your first session.  However, if you reschedule within 48 hours of your scheduled appointment, the payment will be reimbursed or applied to your next appointment.  If a 48 hour notice has not been given to cancel or reschedule your scheduled session your payment will have paid for the session slot you are no longer attending.

As a courtesy, I will give you a reminder text to make your initial payment to hold your slot.  However, If I have not received your payment within 48 hours of your scheduled appointment and you have not contacted me to make other arrangements, your session will be automatically canceled. 

  

1.   Intake Form 

2.  Receipt of HIPAA & Disclosure Statement  

3.  Credit Card Preauthorization

4.   COVID 19 Waiver

5.  Disclosure Statement 

6.  Notice of Privacy Practices



Remote Therapy Sessions:

If you are a first time client requesting therapy services remotely via Zoom, please download and fill out the above forms along with the below "Teletherapy Informed Consent" form. Once completed, please scan and email to me all the forms prior to your scheduled remote session. Please read the above information for holding your scheduled session slot. 

Teletherapy Informed Consent


Insurance Questionnaire:

I have included an Insurance Questionnaire to help you determine if reimbursements for psychotherapy services are available from your insurance company.  

Insurance Questionnaire   


 Note: To download Adobe Acrobat Reader for free, click here.

Contact Me

LOCATION

Appointment Times

Monday:

5:00 pm-9:00 pm

Tuesday:

10:00 am-2:00 pm

5:00 pm-9:00 pm

Wednesday:

10:00 am-2:00 pm

5:00 pm-9:00 pm

Thursday:

10:00 am-2:00 pm

5:00 pm-9:00 pm

Friday:

12:00 pm-5:00 pm

Saturday:

Closed

Sunday:

Closed