Helpful Forms

If you’re a first-time client, please review and complete the following forms, and bring them to your first session:

Professional Disclosure and Treatment Contract

Family Therapy Intake Form

Consent to Release Confidential Information to Insurance Company

 

If you would like me to coordinate care with another provider (for example, your psychiatrist, endocrinologist, etc.), complete this form:

Consent to Release Form

If you would like to provide feedback on how your therapy sessions have been at any time throughout the process, please click the link below to complete online, or download the below Customer Feedback Form Microsoft Word document and submit via email, fax or postal mail:

Click Here to take survey

Customer Feedback Form

WARNING! Electronic communications may not be secure! Please do not send sensitive information via regular email. If you wish to send confidential information, such as insurance information, I will provide a link to an encrypted email program to increase security for these transmissions. Please read and sign the last page of my Social Media Policy before contacting me via electronic communications.

My Office Privacy Polices and Procedures

Electronic Resources and Social Media Policy   (Read related blog post)

Note: To download Adobe Acrobat Reader for free, click here.

 

For directions to the office at 3214 Purdue Pl NE, click on the link below:

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