Forms
Please download, fill out and bring the following for your first appointment with Andrea:
Adult (anyone over the age of 18): Client information, Adult intake form, HIPAA form
Minor (anyone 17 and under): Client information, Child Intake, HIPAA form
Couples or family: Client information (only one) and adult or child intake form for each participant
Due to confidentiality restrictions, if you'd like me to speak with another professional (court, CPS, psychiatrist, attorney, school, etc), person of your choosing regarding billing and/or treatment information I need a signed consent to release information form.
Adult (anyone over the age of 18): Client information, Adult intake form, HIPAA form
Minor (anyone 17 and under): Client information, Child Intake, HIPAA form
Couples or family: Client information (only one) and adult or child intake form for each participant
Due to confidentiality restrictions, if you'd like me to speak with another professional (court, CPS, psychiatrist, attorney, school, etc), person of your choosing regarding billing and/or treatment information I need a signed consent to release information form.
| clientinfopp_insur_v5.docx__1_.pdf |
| adultintakeppv5.docx.pdf |
| childintakeppv5.docx.pdf |
| hipaa_pp_rev1.pdf |
| roippv1.docx.pdf |
