Adults:
Please download the forms below and fill out these four forms for our first meeting. Email all four forms to either of the emails listed on my contact page. 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 read below (no need to print).
Intake - Adult
Consent to Treatment
Financial Agreement
HIPAA Agreement (Print and sign the signature page only. No need to print all five pages).
Intake - Minor
Treatment of Consent For Minors
Assessment Forms
Please download the forms below #’s 1, 2, and 3, and fill them out before our first meeting. Email the forms to either of the emails listed on my contact page. NOTE: Form #4 will need only be filled out if I specifically request it of you.
(1) GAD-7
(2) PHQ-9
(3) ACE
(4) DES-2
Other Forms
HIPAA Agreement (Print and sign the signature page only. No need to print all five pages).
Release of Information
Notice to clients and prospective clients:
Under the law, healthcare 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.
For Oregon Clients Only:
Professional Disclosure Statement For Oregon Residents (PDS)
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