Helpful Forms

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

Client Intake Form
Limits of Confidentiality/Cancellation Policy Form
Since it is becoming more time-consuming to deal with my client's heath benefits , I am asking new patients to obtain as much information as they can about their insurance policy. Below ia a sample of the questions to ask:
______________________________________________________________________________________________________________________________________________________________________________

Insurance Info:
Please provide the following insurance information. Complete downloaded form to bring with you to uour inital appointment:
Insurance Company
Name________________________________________________________________________________________________________
Policy effective
Date______________________________________________________________________________________________________
____________________________________________________________________________________________________
Authorization
Number_______________________________________________________________________________________________________
Yearly deductable_______________________________________________________________________________________________
Co-payment
amount_____________________________________________________________________________________________________
% insurance company will pay after deductible has been met_____________________________________________________________
Number of visits for the year_______________________________________________________________________________________
Client's Signature____________________________________________________________________________________________

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

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