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The future depends onwhat you do in the present
African American Couple

NEW PATIENT FORMS

If you're a new client, please complete the following forms and bring them to your first therapy session.





 


PLEASE DOWNLOAD THE FOLLOWING FORMS-COMPLETE/BRING TO 1st APPT.:

EVERYONE:
New Patient Intake Form
Release of Information Form
Debit Card Authorization Form
HIPPA Notice of Privacy Practices
Consent Form and Financial Agreement

AND--

FOR ADULTS & CHILDREN 12 YRS/OVER:
Health and Wellness Questionnaire-1
Health and Wellness Questionnaire-2

OR--

FOR COUPLES ONLY-TO BE COMPLETED, INDEPENDENTLY, BY EACH PARTY:
Relationship Report Card-Myself
Relationship Report Card-Partner
Relationship Report Card-Relationship


GROUP THERAPY REGISTRATION FORM

Note: To download Adobe Acrobat Reader for free, click here.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.