Helpful Forms

Before we meet each other in person for the first time, you will need to register as a client who is seeking a first appointment. During this consultation session, you will explore the possibility of working with me as your psychotherapist and counselor. There are two ways to register. You can come to the office and fill out all the registration forms before your first appointment. It should take at most 30 minutes. The forms will be in a folder in the far left corner of the reception window.

Or you can download and fill out the forms below and bringing them with you, along with your Driver's License for identification. Still, even with completed forms in hand, please come around 10 minutes early for your first appointment.

Please be aware that I will need to know the medications your are taking: names, dosages, frequency. For example, Celexa 20 mg twice daily. These can be included on the Demographic Data Form listed below or you can bring in a separate list.

If you are using insurance for my services, please bring your insurance card. If you are coming with your spouse, only one of you need to register as the identified patient. In case your insurance company requires authorization for outpatient mental health services, it is important that you call them and get the authorization before our first appointment. If you do use insurance, please fill out the top part of the Health Insurance Claim Form below through boxes 12 and 13, both of which you sign.

If you want me to exchange information with any physician other than a psychiatrist, please fill out and sign the Physician Communication form that is next to last on this list. Even if you don't want the exchange, please sign and check Option B to refuse.

Please read HIPAA Privacy Notice . This Notice is for your information and does not have to be brought with you. There is also more information on the Privacy and Policy page.

If you and your spouse are interested in marital therapy, only one of you will register as the patient. The patient spouse will need to include the other spouse on the Consent for Mental Health Services Form. In addition, there are two more forms. The Outpateint Services Agreement for Collaterals Form is to be read and signed by the non-patient spouse. Both spouses are are to read and sign the Informed Consent for Spouses Form to protect the couple's therapy from possible legal proceedings.


If you would like me to coordinate care with another mental health provider  (for example a psychiatrist or a previous therapist), complete this form to authorize release of Protected Health Information:


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Contact Me

Location

Availability

Primary

Monday:

10:00 am-4:00 pm

Tuesday:

10:00 am-4:00 pm

Wednesday:

10:00 am-4:00 pm

Thursday:

10:30 am-4:30 pm

Friday:

10:00 am-1:00 pm

Saturday:

Closed

Sunday:

Closed