Client Forms

Intake Forms

Please print and fill out these 5 forms for our first meeting. The intake form is to be filled out by each person. The other forms have room for multiple signatures and can be shared.  The HIPAA Notice of Privacy Practices can be found further down this page.

heart-shaped rock that says hope

Intake Form

Professional Disclosure Statement 2024

Informed Consent to Treatment

Fee for Services Agreement 2024

Consent to Telehealth Services

Other Forms

Release of Information

HIPAA Notice of Privacy Practices

Preparation for Online Therapy

Notice to clients and prospective clients: Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask for a Good Faith Estimate before you schedule a service, or at any time during treatment.  If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. For questions or more information visit

Jean Vanlue, MA, LPC, LMFT


528 Cottage St. NE,
Suite 300,
Salem, OR 97301