Intake Forms

Intake Forms

Client Demographic Information

This form asks on page 1 to fill out one of two sections either for adult clients (18 and up) filling out the first section or for children/adolescents, skipping the first section and filling out the second section.  The next two pages are our professional service agreement, providing and outlining cancellation policy, fees, emergency procedures, confidentiality, and more, and requires client initials at each paragraph, with a signature at the end.  If using BCBS PPO coverage, you will read over and sign page four and the top of page 5 giving us permission to submit claims to BCBS on your behalf.  If paying out of pocket for services you can skip page four and read over page 5 and sign at the bottom.

Card on File Agreement

For purposes of payment, if you would like to use a credit card as a form of payment for session fees, copays or coinsurance, you will fill out this form, electing the credit card you would like to use (you are welcome to pay by check, credit card, or cash, whatever is most convenient for you, this form is provided if you prefer to use a credit card).

HIPPA: Notice of Privacy Practices

No signatures required or filling out is required and nothing here to return to us. However this form is 3 pages that outlines all the federal law on confidentiality provided to you and everything we do to protect your confidentiality within our work with you (it is required by law that we provide this to you).

Receipt of HIPPA

A signature page acknowledging that we’ve provided you our HIPPA Notice of privacy practices

Authorization to Release Protected Information

Use this form if you would like to authorize us to release your clinical records to a designated person or organization.