If you're a new client, please complete the following forms.
Client Intake Form 2018 to be completed and returned prior to the appointment date.
Limits of Confidentiality/Therapy Cancellation Policy
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
An important note about specific prescriptions
Policy Regarding Prescription of Controlled Substances
It may be that during your treatment you will be prescribed a controlled substance such as Adderall, Ambien, Xanax, Ritalin or other similar medication. Safe use of these medications imposes an extra burden of responsibility on both of us. As part of my responsibility I will not authorize early refills or replace lost prescriptions. It is important on your part to understand that I am required to check before any refill is given to see that no similar prescription has been obtained elsewhere. If I find that to be so our doctor patient relationship will terminate.
please initial here_____
Note: To download Adobe Acrobat Reader for free, click here .