Forms

Rebecca

“Happiness is not something you postpone for the future; it is something you design for the present.”   

– Jim Rohn, Entrepreneur, Author, and Motivational Speaker

If you are a new client, please print and complete the appropriate following forms and scan them to me prior to our initial appointment. For those who clients who will be participating in video sessions, please also complete the Telemedicine Consent form located at the bottom of this page.

For Adult Clients:

For Minors:

*If your child’s parents or legal guardians are divorced, please bring a photocopy of the court decree showing the dissolution of the marriage. If  you are unable to make a photocopy, I would be happy to do so during our first appointment.  

For All Clients:

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, child’s teacher, etc.), complete the form below to authorize the exchange or release of your psychotherapy information.

 For Telemedicine (Videoconferencing)

For those client’s who have arranged to meet via video, please complete the Telemedicine Consent Form below in addition to the required consent forms listed above.