Forms

Please print and fill out one of these forms and the Consent to Treatment form. If I will work with you as a couple, each person needs to fill out one’s own set of forms. Please mail, email or fax these forms to me.

• Adult Information Form

• Child Information Form

Also, all clients need to complete the following form (For the treatment of a child, all legal guardians need to sign this form):

• Consent to Treatment
• Consent to Treatment (minor)

If a child is being treated, please fill out the Child Information Form and the Child Consent to Treatment Form by both parents unless a legal document addresses single Guardianship. Please mail, email or fax these forms to me.

In order to coordinate treatment with other current treating professionals, please fill out this form:

• Auth to Release Info

For your information:

• Hippa Privacy Act

• Patient Rights and Responsibilities