Client Forms

First Session Forms

Intake Assessment – Contact info, emergency contact info, and a brief synopsis on personal and family history (required for first session)

Mandatory Disclosure Statement – Goes over terms of confidentially, what types of information require mandatory reporting, scheduling, rates, etc.

Electronic Payment Authorization – Form used to gain credit card payment information. Once this is input into Point of Sale, personal financial information will be discarded.

Additional Forms

Collateral Disclosure – Use this form if you are joining for therapy along with a spouse or family member but are not a regular client.

Authorization for Use or Disclosure of Private Health Information – With permission from the client, this form is used to gain information from other health care providers to assist in continuity of care.

“NO-Secrets”-Policy  – For couples seeking therapy when the couple is considered the client. No secrets refers to the therapist not holding any confidential information that may be disclosed in an individual session when meeting as a couple.

EMDR Informed Consent – Use this consent form if you are coming in for your first EMDR session.

* If you have questions about any of these forms please contact me at (719) 246-5693

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