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Forms

If you're a new client, please print and complete the following forms and bring them to your first therapy session.  This will save us a great deal of time, so that our first session can focus primarily on assessing what is breaking down for you and/or your family.  Also, please feel free to ask any questions if you do not understand something in a form; you can call me directly, email me questions, or save the questions for our first session.  I want to make sure that you fully understand what you are signing. 

 

 

 

 

 


If the person receiving services is under the age of 18, please complete the Child Therapy form below. 

 

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, school, etc.) or want me to speak to another family member or friend regarding your treatment, complete the authorization form below to permit release of psychotherapy information or receipt of new information.

If you wish to get the assistance of a spouse, family member, or friend in your treatment and therapy sessions, please print the Collateral Contacts form.

If you have TRICARE insurance coverage and intend to use this coverage to pay for part of your services, please print and complete the Tricare Insurance form below, permitting time to get release (authorization #) or an understanding of your coverage from your representative.  I am now an in-network provider for TRICARE.  Please consult with your TRICARE representative regarding an explanation of your coverage and any deductible requirments that may apply. 

If you wish to pay for services with a credit card, please print, complete and sign the Credit Card Authorization form.


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