Intake Forms
NOTE FOR ALL WEBSITE GUESTS AND/OR POTENTIAL NEW CLIENTS:
The first three visits to my office or telehealth sessions are for an evaluation to see if my practice is appropriate for your needs and for us to establish a treatment relationship.
In addition, any communication between website guests and this therapist, or downloading forms from this site, does not guarantee that a treatment relationship will be established. While in my office, or via telehealth sessions, if it is determined that my services do not meet your needs, I will offer several referrals to you to explore. I do not offer therapy services via this website. I offer telehealth via telephone or HIPAA compliant Zoom. Please note that although efforts are made for encrypted security, telehealth sessions are not able to be as secure as in office meetings.
INTAKE FORMS
1 – Consent for Counseling & Treatment
This form lists and describes my credentials, professional fees, theoretical orientation and parameters of my practice, the limitations and benefits of counseling, parameters of confidentiality/privacy/privilege, duty to warn and mandated reporting of abuse, emergency procedures, office policies – which includes information such as – cancellation policies, reasons for possible termination of the therapeutic relationship, and referral, etc. Please read this form carefully because it explains your rights and the limitations of your rights.
2 – HIPAA Form
Notice of Policies and Practices to Protect the Privacy of Your Health Information
3 – TeleCounseling Informed Consent
4 – Art Release Form
* download & print the forms
* complete forms to the best of your ability
* initial every page, sign and date
* make a copy of the forms for yourself
* include a copy of your driver’s license
* mail forms to my office
PO Box 6806
Malibu, CA 90264
NOTE: If you wish to send the package via email, there is a greater confidentiality risk, and you may chose to do so if you accept the responsibility. If you take this pathway, please place the documents in an app such as DocuScan so that the documents are signed and dated for my files.
Marriage & Family Therapy
