Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

• Client Psychotherapy Intake Form
• Limits of Confidentiality/Therapy Cancellation Policy

Self-Pay Clients

Please fill out the following sliding fee evaluation form and return either by fax to (866) 824-9980 or email to [email protected]

Your application will be reviewed to determine the sliding fee for the initial intake and the subsequent therapy sessions. The Sliding Fee Agreement will be signed at your first meeting.

Thank you for considering our services.

• Sliding Fee Scale Evaluation

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

• Authorization to Disclose Information Form

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