- Client Psychotherapy Intake Form
Limits of Confidentiality/Therapy Cancellation Policy
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
- Authorization to Disclose Information Form
|Client Psychotherapy Intake Form|
|Limits of Confidentiality/Therapy Cancellation Policy|
|Authorization to Disclose Information Form|
Note: To download Adobe Acrobat Reader for free, click here.If you plan to use insurance, before your appointment, please call the 800 number on your card and determine your co-pay or deductible. Please bring your insurance card with you to your visit. I also accept MasterCard, Visa, Cash or Check.
All communication is protected by law as confidential and privileged.
The law protects the relationship between a client and a psychotherapist and information cannot be disclosed without written permission.
- Suspected child abuse or dependant 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.
- If a client 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.