Important Documents

After you have scheduled your very first visit with me, please print the following documents, fill them out, and sign them before arriving for your appointment. Completing these ahead of time will allow us to begin on time and maximize the potential for your session.

• Consent for Treatment (Agreement for Services):
  • Consent for Treatment (PDF)
• Notice of HIPAA Privacy Practices (How your personal information is used – Sign 1st Page):
  • Notice of Privacy Practices (PDF)
• Adult Client Information Form (18 years of age and up):
  • Adult Client Information Form (PDF)
• Youth Client Information Form (0-17 years of age, guardian to complete):
  • Youth Client Information Form (PDF)
• Insurance Agreement Form (For clients using their insurance benefits):
  • Insurance Agreement Form (PDF)
• Insurance Opt-Out Form (For clients who decide to opt-out of using their insurance benefits for which I am In-Network):
  • Insurance Opt-out Form (PDF)
• Distance/Online Counseling Agreement Form (For established clients who have been screened for this service):
  • Distance Counseling Consent and Agreement (PDF)
• Releases of Information (For John to be able to coordinate care and communicate with others regarding your treatment)
  • Authorization for Release of Information – Adult (PDF)
  • Authorization for Release of Information – Minor 0-17 (PDF)

To view, download, and print these documents, you must have Adobe Reader installed on your computer. Please click the link below to obtain a copy of Adobe Reader.