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.
Professional Disclosure Statement 2024
Fee for Services Agreement 2024
Consent to Telehealth Services
Other Forms
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 www.cms.gov/nosurprises.
