PAPERWORK, FEES AND FORMS :

Fees: $135.00 for individual therapy; $150.00 for couple’s therapy.  I do offer sliding scale.

This forms page is for the convenience of my patients. The forms are ‘auto filled’ with MS Word.  Please print and fill out the required forms prior to our first visit. Please bring completed forms with you to our first appointment. Thank you.

 

Each new or returning patient must fill out the “New Patient Intake Form”, and “Exchange Confidential Info“,    form and they should review the “Privacy Summary” [You do not need to print privacy summary page. It is for your information only]. “Exchange Confidential Info form is to be completed if you want me to share information with your physician.

 

If the ‘patient’ is a child, the caregiver needs to fill out the Child Patient History* form and “Agreement for Minors” form.

 

If the ‘patient’ is a couple, they need to fill out the “CouplesHistory” form and “Alcohol Assessment” form. Please have each person fill out their own form.

 

If the ‘patient’ is an individual, they need to fill out the “Patient Personal History” form and “Alcohol Assessment” form.

 

Fill out the form below

and click submit to send a secure email with your insurance information:

Comments or questions are welcome.

* indicates required field

List of on-line Forms in PDF format

Click on the form to view it and print it out.

New Patient Registration New Patient Intake Form*

 

Privacy Summary Privacy Summary

 

Exchange Confidential Info Exchange Confidential Info

 

Child Patient History Child Patient History*

 

Agreement for Minors Agreement for Minors*

 

Couple History CouplesHistory

 

Alcohol Assessment Alcohol Assessment*

 

Patient Personal History Patient Personal History*