Forms

For your your convienience, please download and bring with you to first appointment



Forms for all service

HIPPA notice: this form explain how the law regulates your privacy i.e. when and with whom I can or must share your health information. By signing the form you acknowledge that I provided you this information.

Intake Form: the purpose is to provide your basic demographic/contact information and your psycho-educational-social history. When you do this I will be able to devote our initial evaluation for the most part to your presenting concern, versus spending time collecting history.

Medical Intake Form: as medical conditions and medications can impact psychological function, it is important to provide this medical information. Make sure to list the dose and time at which you take medication

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Forms for all therapy services

Office Policies and Consent to Treatment: this form explains my policies. By signing you agree to the policies and to receive the treatment you requested (i.e. therapy)

Reason for Therapy: this form is designed to help you think through what you want to work on and what you want to achieve. Take your time with this form: it’s a tool I put much thought in to help you jumpstart your therapy and use your face to face time in the most effective possible way

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Forms for Neuropsychological Evaluation

Office Policies and Consent to Treatment: this form explains my policies. By signing you agree to the policies and to receive the treatment you requested (i.e. neuropsychological evaluation).

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Additional Consent Form for RRT

Consent to Treatment with RRT: this form is in addition to the Office Policies Form and explains specific issues related to hypnosis.

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