Forms

Please complete the Client Information Sheet and Contract for Services and the Teletherapy Agreement Forms prior to the day of your initial appointment:

Client Information Sheet and Contract for Services (required)

Teletherapy Agreement (required)

Good Faith Estimate Form
(required for clients who do not have insurance or do not intend to submit for out of network benefits)

Authorization to Release Information

By completing and submitting online, you are agreeing to electronically signing these agreements.  Electronic signatures appearing on these agreements are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Medicare Patient Contract (required for those who have Medicare).  If you have Medicare, please be advised I have opted out of Medicare and you will need to complete this agreement in order to receive psychological services from me.  This agreement indicates you know I do not accept Medicare and you agree not to submit any services rendered by me to Medicare for reimbursement.  Please click on the link and download to review and sign the form and return to me.

In person psychotherapy meetings unavoidably increases the risk of viral infection for all involved (close up person-to-person verbal interactions, in close quarters, for extended periods of time).  Teletherapy appointments are a safe way of limiting that exposure.  All clients meeting in person are expected to notify me if they have any symptoms, exposure to others who have symptoms. or have tested positive for covid or other illnesses so that we can meet virtually for everyone’s health and safety.