Forms

My new life chapter one concept for fresh start, new year resoluNew clients: please print and complete these forms and bring them with you to the first session. This allows us to save time in the session. If you are unsure about any item, please leave it blank and we will discuss it together.

Adult Clients

  1. Medical Authorization
  2. Payment Authorization
  3. Symptom List
  4. Authorization to Videotape Sessions
  5. Release of Information (Please print 1 form for EACH person you want information released to: spouse if couples’ counseling, psychiatrist if under medication, physician for physical pain, etc.)

Minor Clients

  1. Medical Authorization
  2. Payment Authorization
  3. Symptom List (to be completed by client, not parent)
  4. Authorization to Videotape Sessions
  5. Release of Information (Please print 1 form for EACH person you want information released to: school, each parent if a teenager, non-custodial parent if separated/divorced, psychiatrist if under medication, physician for physical pain, etc.)