Forms

Professional Discolsure Statement

 

​Individual Counseling Intake Form

 

Individual Checklist of Concerns

 

Couples Counseling Intake Form

 

Couple Counseling Checklist of Concerns

 

Release of information

 

Confidentiality and Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

 

Exceptions include:

  • Suspected child abuse of dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.

  • If a client is threatening serious bodily harm to another person(s), I must notify the police and inform the intended victim(s).

  • If a client threatens or intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.

Cancellation Policy
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