Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, Denver Office 837 Sherman St. Denver, CO 80203

Size: px
Start display at page:

Download "Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, 80920. Denver Office 837 Sherman St. Denver, CO 80203"

Transcription

1 Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, Denver Office 837 Sherman St. Denver, CO Welcome to my practice. I am honored that you are giving me the opportunity to be of help to you. It is my belief that the foundation of effective therapy is a solid relationship between a therapist and a client. I strongly believe you should feel comfortable with the therapist you choose. To help you decide if I will be a good fit for your needs, this document contains important information about me and the professional services I offer. As you read this form, I welcome you to note any questions, concerns, or suggestions you might have. I would be happy to discuss these with you at our next meeting. ABOUT ME I have a Doctorate in Counseling Psychology from the University of Northern Colorado. My training program was accredited by the American Psychological Association, and included a year-long internship. Additionally, I completed a Master s Degree in Community Counseling and a Bachelor s Degree in Psychology. I am a licensed psychologist in the state of Colorado and my license number is Also, I am an active member of the American Psychological Association. I have 12 years of experience in the mental health field and have worked in a variety of settings. I am trained and experienced in individual therapy, couples therapy, and family therapy. I also provide consultation services and supervision to therapists in training. I have been trained to work with adults, adolescents, or children. There are several different approaches to therapy that I have been trained in, and may use in my work with clients. My primary approach with clients is based on Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy has been shown to be an effective form of treatment for many different mental health concerns, some of which include depression, anxiety, eating disorders, etc. I also integrate techniques from Interpersonal and Humanistic approaches, Dialectical Behavioral Therapy, Motivational Interviewing, and Solution-Focused Therapy. Additionally, I have been trained in Eye Movement Desensitization and Reprocessing (EMDR). I specialize in the treatment of eating disorders and body image concerns. At the same time, I am also considered a generalist, which means that I am qualified to work with all types of concerns. My special interest areas include women s mental health, anxiety, depression, relationship issues, family issues, grief and loss, trauma, sexual identity, life transitions, and identity development. I am an independent practitioner and am not legally or professionally affiliated with any other mental health professional.

2 ABOUT PSYCHOTHERAPY I view therapy as a collaborative partnership between therapist and client. I expect us to plan our work together. I value your input and will actively seek to understand factors that can contribute to your success in therapy. Additionally, I would like to have input from you on how you feel you are progressing in therapy, or areas that you feel are not being addressed. From time to time, we will look together at our progress and goals. If we think we need to, we can then change our treatment plan, its goals, or its methods. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. At times, I will ask you to practice things we are working on outside of our meetings. I might ask you to do exercises, keep records, and read to deepen your learning. As with any powerful treatment, there are some risks as well as many benefits associated with participation in therapy. One risk involves the possibility that clients will have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. Sometimes, too, a client s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about your progress. I highly value the relationships I form with clients. However, because of my ethical and legal obligations, there are limits to our relationship I d like you to understand. In order to be most helpful to you, I can only be your therapist. I cannot be a close friend to or socialize with any of my clients, and I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. Sexual intimacy between a client and therapist is never appropriate and is illegal in Colorado. Please report this to the below address if this has ever happened to you.

3 ABOUT YOUR RIGHTS AS A CLIENT As a client seeking mental health services, you have certain rights. These include your right to seek a second opinion from another therapist or your right to terminate this therapy at any time. You are also entitled to receive information regarding the methods of therapy, techniques used, the duration of therapy, if known, and the fee structure. Please ask if I do not fully provide you with this information or if you have any questions. The practice of psychology in Colorado is regulated by the Colorado Department of Regulatory Agencies. The agency within the Department that has responsibility for licensed and unlicensed psychotherapists is the Department of Regulatory Agencies. Any questions, concerns, or complaints regarding your mental health treatment may be directed to: ABOUT OUR APPOINTMENTS State Grievance Board 1560 Broadway, Suite 1370 Denver, Colorado Phone: The very first time I meet with you, we will need to give each other much basic information. I usually schedule minutes for this first meeting. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If you decide to begin therapy with me, we will usually schedule one 50-minute session per week at a time we agree on. There may be times when sessions may be longer, or more or less frequent depending on your course of treatment. We can schedule meetings for both your convenience and mine. An appointment is a commitment to our work. We agree to meet at my office and to be on time. If I am ever unable to start on time, I ask your understanding. I also assure you that you will receive the full time agreed to. If you are late, we will probably be unable to meet for the full time, because it is likely that I will have another appointment after yours. A cancelled appointment delays our work. I will consider our meetings very important and ask you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please give me as much notice as possible. PROFESSIONAL FEES AND PAYMENT I require payment by credit card, cash, or check at the time of service. If payment is not rendered in a timely fashion and I am unable to collect my fee, I may in some cases employ the services of a collection agency. In case a check does not clear, the fee for returned checks is $50. My current regular fees are below. You will be given advance notice if my fees should change.

4 Regular therapy services: My fee for a standard 50-minute therapy session is $ Please pay for each session at its end. I have found that this arrangement works best. It also allows me to keep my fees as low as possible, because it cuts down on my bookkeeping costs. Other payment or fee arrangements must be worked out before the end of our first meeting. Telephone consultations: I believe that telephone consultations may be suitable or even needed at times in our therapy. If so, I will charge you our regular fee, prorated over the time needed. If I need to have long telephone conferences with other professionals as part of your treatment, you will be charged for these at the same rate as for regular therapy services. If you are concerned about all this, please be sure to discuss it with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge for calls about appointments or similar business. Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes, I will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis. Other services: I charge $130 per hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. I realize that my fees involve a substantial amount of money, although they are well in line with similar professionals charges. For you to get the best value for your money, we must work hard and well. Because I expect all payment at the time of our meetings, I do not send bills. If you would like a statement of the services I have provided to you, please let me know. A statement can be used for health insurance claims, as described in the next section. It will show all of our meetings, the charges for each, and how much has been paid. CANCELLATIONS I will reserve a regular appointment time for you into the foreseeable future. I also do this for my other clients. Therefore, I am rarely able to fill a cancelled session unless I have several weeks notice. If you are unable to keep an appointment, please notify me as soon as you become aware of this fact. If you cancel or miss an appointment without providing 24-hour notice, you will be billed for the entire session. Emergency situations are exceptions to this

5 policy, and will be evaluated and discussed in the context of your treatment on a case-by-case basis. INSURANCE Because I am a licensed psychologist, many health insurance plans will help you pay for therapy and other services I offer. Since health insurance is written by many different companies, I cannot tell you what your plan covers. It is very important that you find out exactly what mental health services your insurance policy covers. Please read your plan s booklet under coverage for Outpatient Psychotherapy or under Treatment of Mental and Nervous Conditions. Or call your employer s benefits office to find out what you need to know. I am not a member of any health insurance plans or panels. However, I am happy to supply you with all of the documentation necessary to file an out-of-network provider claim including, standard diagnostic and procedure codes for billing purposes, the times we met, my charges, and your payments. You can use this to apply for reimbursement. If you choose to submit this to your insurance for reimbursement, it is your responsibility to pursue the claim. IF YOU NEED TO CONTACT ME I am often not immediately available by telephone. While I am often in my office, I do not take calls when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If, during our work together, an emergency does occur which requires immediate attention, please call 911 or go to your nearest hospital for assistance. I urge you to inform me of these events as they may impact your therapy. It is important that you determine the level of emergency care that you would like to have in a therapist. My practice is not designed to help those who require 24-hour care or crisis and emergency care. In the event of an emergency, it may be necessary for you to contact another health care provider. If this does not seem to meet your needs, please let me know and I will provide you with the names of therapists who provide 24-hour care. IF I NEED TO CONTACT SOMEONE ABOUT YOU If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you perhaps a relative, spouse, or close friend. I am also required to contact this person, or the authorities, if I become concerned about your harming someone else. Please write down the name and information of your chosen contact person in the blanks provided:

6 Name: Address: Phone: Relationship to you: ABOUT CONFIDENTIALITY Confidentiality is an important component of therapy and one that I take very seriously. I will treat all the information you share with me with great care. It is your legal right that our sessions and my records about you be kept private. That is why I ask you to sign a release-ofinformation form before I can talk about you or send my records about you to anyone else. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me. In all but a few rare situations, your confidentiality (that is, our privacy) is protected by federal and state laws and by the rules of my profession. Here are the most common cases in which confidentiality is NOT protected: If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable with telling. Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court that you are seeing me, I may then be ordered to show the court my records. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. Please consult your lawyer about these issues. If you make a serious threat to harm yourself or another person, the law requires me to try to protect you or that other person. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the client. If my client threatens to harm or kill herself/himself, I may be obligated to call the police, seek hospitalization for him or her, or to contact family members or others who can help provide protection. If I believe that a child, elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency. These situations rarely occur in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. There are two other situations in which I might talk about part of your case with another therapist. I ask now for your understanding and agreement to let me do so in these two

7 situations. First, when I am away from the office for a few days, I have a trusted fellow therapist cover for me. This therapist will be available to you in emergencies. Therefore, he or she needs to know about you. Of course, this therapist is bound by the same laws and rules as I am to protect your confidentiality. Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your information private. Your name and other identifying information will be changed or omitted, and they will be told only as much as they need to know to understand your situation. Clients Under the Age of Eighteen If you are under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that gives up their access to your records. If they agree, I provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information (except in the cases of imminent danger), I will do my best to discuss the matter with you and to handle any objections you may have about what I am prepared to discuss. Except for situations like those I have described above, I will always maintain your privacy. If your records need to be seen by another professional, or anyone else, I will discuss it with you. If you agree to share these records, you will need to sign an authorization form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits. Please ask me if you have any questions regarding confidentiality.

8 CONSENT FOR TREATMENT I acknowledge that I have received, have read (or have had read to me), and understand the preceding information regarding Dr. Angie Dunn s degrees, credentials, practice, and privacy policies. I have read the preceding information in full and understand my rights as a client. I have had all my questions answered fully. I do hereby seek and consent to take part in the treatment with Dr. Angie Dunn. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may seek a second opinion or stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment (for example, if my treatment has been court-ordered, I will have to answer to the court). I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment. My signature below shows that I understand and agree with all of these statements. I consent to therapy, including assessment, evaluation, treatment, and/or referral. Signature of client (or person acting for client) Printed name Date Relationship to client (if necessary) I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services. I, Angie Dunn, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Angie Dunn, Ph.D. Date Copy accepted by client Copy kept by therapist

Sterman Counseling and Assessment

Sterman Counseling and Assessment Information for Clients Welcome to Sterman Counseling and Assessment. We appreciate the opportunity to be of assistance to you. This packet answers some questions about therapy services. It is important

More information

Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835

Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835 Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835 Professional Policies and Consent to Treatment Welcome to my practice. I appreciate your giving me the

More information

Jennifer L. Trotter, Ph.D.

Jennifer L. Trotter, Ph.D. Jennifer L. Trotter, Ph.D. Telephone: 248-880-4966 - Email: JenniferLTrotter@gmail.com Licensed Clinical Psychologist Address: 25882 Orchard Lake Road - Suite L-4 - Farmington Hills, MI 48336 OUTPATIENT

More information

Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355

Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355 Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355 CLIENT INFORMATION AND CONSENT Welcome to my practice. This document

More information

David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457

David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457 David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457 DISCLOSURE INFORMATION & CONTRACT FOR PSCYHOLOGICAL SERVICES DATE: CLIENT NAME: BIRTHDATE: ADDRESS:

More information

Client Brochure, Disclosure Statement, and Consent for Services

Client Brochure, Disclosure Statement, and Consent for Services DENVER THERAPY & ASSESSMENT Alexandra McDermott, PsyD Licensed Psychologist 600 South Cherry Street, Suite 230, Denver, CO 80246 Alex@DenverTherapyAssessment.com (720) 485-4194 Client Brochure, Disclosure

More information

INFORMATION FOR CLIENTS

INFORMATION FOR CLIENTS INFORMATION FOR CLIENTS Psychotherapy Practice Information Brochure Kate Miller, PsyD, HSPP Clinical Psychologist Director, Under the Umbrella, LLC 4315 E. 3 rd St. Bloomington, IN 47401 (812) 614-2040

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT ANA I. AGUIRRE-DEANDREIS, Ph.D. Clinical Psychologist 6325 Executive Boulevard, Rockville, Maryland 20852 Tel:(301)571-2324 Fax:(301)770-0276 INFORMED CONSENT FOR TREATMENT This document contains important

More information

TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401

TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Minor Consent for Treatment and Service Agreement Welcome to Tidelands Counseling!

More information

San Diego Psychotherapy, Inc. Shoshana Shea, Ph.D. Licensed Psychologist #PSY19888

San Diego Psychotherapy, Inc. Shoshana Shea, Ph.D. Licensed Psychologist #PSY19888 San Diego Psychotherapy, Inc. Shoshana Shea, Ph.D. Licensed Psychologist #PSY19888 3821 Front Street San Diego, CA 92103 tel. (619) 269-2377 fax (619) 294-3225 www.shoshanashea.com OFFICE POLICIES, AGREEMENT

More information

Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 mail@drrebeccaihoward.com

Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 mail@drrebeccaihoward.com Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 mail@drrebeccaihoward.com CLIENT INFORMATION AND CONSENT Welcome to my practice. This document contains important

More information

Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889

Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document

More information

PSYCHOTHERAPY CONTRACT

PSYCHOTHERAPY CONTRACT Aaron J. Dodini, Ph.D. Licensed Clinical Psychologist Licensed Marriage & Family Therapist PSYCHOTHERAPY CONTRACT Welcome to my practice. This document contains important information about my professional

More information

Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional

More information

COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT

COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT Jill Squyres, Ph.D. PO Box 2125 Eagle, CO 81631 drjsquyres@mac.com 970.306.69.86 (ph) 866.512.0078 (fax) COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT This services agreement

More information

Brian Nussbaum, Psy.D. 06/09 1

Brian Nussbaum, Psy.D. 06/09 1 Tampa Psychology Brian Nussbaum, Psy.D. Licensed Clinical Psychologist, FL license# PY6830 27446 Cashford Circle #101 Wesley Chapel, FL 33544 (813) 545-7754 Welcome to my practice. This document contains

More information

GENESIS COUNSELING GROUP, S.C.

GENESIS COUNSELING GROUP, S.C. PSYCHOLOGY SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Mendel Psychological Associates

Mendel Psychological Associates PSYCHOLOGIST- PATIENT SERVICES AGREEMENT This document is an agreement between therapist: and client:. Welcome to our practice. This document (the Agreement) contains important information about professional

More information

Haica Rosenfeld, Psy.D. Licensed Clinical Psychologist 19300 West Dixie Highway, Suite 2 Aventura, FL 33180

Haica Rosenfeld, Psy.D. Licensed Clinical Psychologist 19300 West Dixie Highway, Suite 2 Aventura, FL 33180 1 Haica Rosenfeld, Psy.D. Licensed Clinical Psychologist 19300 West Dixie Highway, Suite 2 Aventura, FL 33180 PSYCHOTHERAPIST PATIENT SERVICES AGREEMENT (Clinical Services, Policies and Procedures) Welcome

More information

Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT

Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT PROFESSIONAL SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Ann Dunnewold, Ph.D., 2012

Ann Dunnewold, Ph.D., 2012 1 Ann Dunnewold, Ph.D. 8140 Walnut Hill Lane, Suite 100 Dallas, TX 75231 (214) 343-1353 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important

More information

Alison J. Bomba, Psy.D.

Alison J. Bomba, Psy.D. Alison J. Bomba, Psy.D. Licensed Psychologist OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please

More information

Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036

Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 PSYCHOLOGIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement)

More information

Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606

Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document

More information

Gay Galleher, Ph.D., A.B.P.P. Board Certified in Clinical Psychology OUTPATIENT SERVICES CONTRACT

Gay Galleher, Ph.D., A.B.P.P. Board Certified in Clinical Psychology OUTPATIENT SERVICES CONTRACT Gay Galleher, Ph.D., A.B.P.P. Board Certified in Clinical Psychology Mailing: 10 State Road, Suite 9, Bath, Maine 04530 Office: 579 Berry s Mill Road, West Bath, Maine 04530 207-443-1016 OUTPATIENT SERVICES

More information

PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT

PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary

More information

Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648

Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Problems in love and work, as well as troubling symptoms like depression and anxiety, often lead people to seek therapy.

More information

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services

More information

RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12)

RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043 1 PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) Welcome to my practice. This agreement contains important information

More information

Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030

Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030 Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030 PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about

More information

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT The Bethesda Group Psychological Services, LLC Old Georgetown Office Park 7988 Old Georgetown Road, 8A Bethesda, Maryland 20814 Phone 301.718.4544 Fax 301.718.4545 info@thebethesdagroup.com PSYCHOTHERAPIST-PATIENT

More information

JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT This document contains important information about my professional and business policies. It also

More information

J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax

J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax jgdol@aol.com www.jgarydolinskyphd.com Psychologist-Patient

More information

Deborah Issokson, Psy.D.

Deborah Issokson, Psy.D. Deborah Issokson, Psy.D. Licensed Psychologist HEALTHCARE PRIVACY AND SECURITY POLICIES PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important

More information

Life Tide Counseling, PC Individual, Marriage and Family Counseling

Life Tide Counseling, PC Individual, Marriage and Family Counseling Life Tide Counseling, PC Individual, Marriage and Family Counseling OUTPATIENT SERVICES CONTRACT Therapist: ( Therapist ) Client: ( Client ) Welcome to Life Tide Counseling, PC ( Life Tide Counseling ).

More information

Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110

Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110 Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110 PROVIDER-PATIENT SERVICES AGREEMENT Welcome to Riegler Shienvold & Associates (RSA). This document (the

More information

TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401

TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Adult Consent for Treatment and Service Agreement Welcome to Tidelands Counseling! Tidelands

More information

OFFICE POLICIES AND SERVICE AGREEMENT

OFFICE POLICIES AND SERVICE AGREEMENT Thomas Cicciarelli, Psy.D. PSY17298 350 Parnassus Avenue, Suite 601. San Francisco, CA 94117. 415-767-5199 OFFICE POLICIES AND SERVICE AGREEMENT Introduction Welcome to my practice. This document contains

More information

PSYCHOLOGIST-PATIENT SERVICES AGREEMENT

PSYCHOLOGIST-PATIENT SERVICES AGREEMENT Helen G. Jenne, Psy.D.,FAACP Board Certified, Clinical Psychology PSYCHOLOGIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional

More information

Information for New Clients

Information for New Clients Information for New Clients Welcome to our practice! This form explains office procedures and relays important information. Your provider will discuss important aspects of the following information with

More information

PATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome!

PATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome! Jeremy Frank, PhD CADC Licensed Psychologist and Certified Alcohol and Drug Counselor Presidential City Madison Building 2 Bala Plaza, Suite Plaza 13 (Pl-13) Bala Cynwyd, Pennsylvania 19004 215-356-8061

More information

James A. Purvis, Ph.D. Psychotherapy Services Agreement

James A. Purvis, Ph.D. Psychotherapy Services Agreement James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist

More information

Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677

Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:

More information

Informed Consent and Clinical Policies

Informed Consent and Clinical Policies THRIVE Center for ADHD and Comprehensive Mental Health Informed Consent and Clinical Policies Welcome to THRIVE. This document contains important information about our professional services and business

More information

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance. Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work

More information

OUTPATIENT SERVICES CONTRACT

OUTPATIENT SERVICES CONTRACT OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Michael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation I,, who was born on and who resides at

Michael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation I,, who was born on and who resides at Michael S. McLane, Psy.D. Licensed Psychologist 12830 Hillcrest Road Suite D233 Dallas, TX 75230 Ph: (972) 620-1225 Fax: (972) 620-4393 Informed Consent to Treatment / Evaluation I,, who was born on and

More information

Michael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation of a Minor Child. who was born on and who resides at

Michael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation of a Minor Child. who was born on and who resides at Michael S. McLane, Psy.D. Licensed Psychologist 12830 Hillcrest Road Suite D233 Dallas, TX 75230 Ph: (972) 620-1225 Fax: (972) 620-4393 Informed Consent to Treatment / Evaluation of a Minor Child I am

More information

PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #

PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone # Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:

More information

Leonard M. Bohanon, PhD Psychologist

Leonard M. Bohanon, PhD Psychologist 2203 Timberloch Pl., Suite 100 PERSONAL DATA RECORD Client Name: Date of Birth Address: City/State/Zip: Home Phone: Cell Phone: SSN: Work Phone: Other Phone: TXDL: Employer/School: Referred to Our Office

More information

A PSYCHOLOGICAL SERVICE DR. PAMELA REBECK

A PSYCHOLOGICAL SERVICE DR. PAMELA REBECK A PSYCHOLOGICAL SERVICE DR. PAMELA REBECK PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT AND INFORMED CONSENT Welcome to my practice. This document (the Agreement) contains important information about my professional

More information

DISCLOSURE AND CONSENT FORM

DISCLOSURE AND CONSENT FORM SCA INTAKE DOCUMENTS Thank you for your interest in Southwest Counseling Associates. This package contains all the documents you would typically receive when you arrive for your first session with an SCA

More information

AGAPE. Therapist Client Services Agreement

AGAPE. Therapist Client Services Agreement Revised 7/1/08 AGAPE Therapist Client Services Agreement AGAPE is a faith-based organization guided by Christian values. As part of its overall mission, AGAPE offers professional counseling and psychological

More information

Psychological Services Contract

Psychological Services Contract Azmaira Maker, Ph.D. Licensed Clinical Psychologist (PSY 21570) 12625 High Bluff Drive, Suite 104 San Diego, CA 92130 Tel: (858) 531-1122 Fax: (866) 861-7731 www.drmaker.net Thank you for inquiring about

More information

oimae ;vnv ;asv ;lskaj; afesldk PSYCHOTHERAPY SERVICES AGREEMENT

oimae ;vnv ;asv ;lskaj; afesldk PSYCHOTHERAPY SERVICES AGREEMENT oimae ;vnv ;asv ;lskaj; afesldk 33493 West 14 Mile Road, Suite 130 Farmington Hills, MI 48331 (248) 851-KIDS (5437) ChildAndFamilySolutionsCenter.com afeaf eafeafew; PSYCHOTHERAPY SERVICES AGREEMENT This

More information

Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997

Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997 Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997 Informed Consent & Agreement for Psychotherapy Services Effective July 7,

More information

JACQUELINE HOOD, PH.D. Licensed Psychologist Licensed Specialist in School Psychologist 972-827-7921 www.dallaschildpsychologist.com.

JACQUELINE HOOD, PH.D. Licensed Psychologist Licensed Specialist in School Psychologist 972-827-7921 www.dallaschildpsychologist.com. JACQUELINE HOOD, PH.D. Licensed Psychologist Licensed Specialist in School Psychologist 972-827-7921 www.dallaschildpsychologist.com Consent Form Welcome to my practice. This document contains important

More information

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document

More information

OUTPATIENT SERVICES CONTRACT

OUTPATIENT SERVICES CONTRACT OUTPATIENT SERVICES CONTRACT Welcome to Urban Wellness. Since this is your first visit, we hope what is written here can answer some of your questions as you seek therapy. Please let us know if you want

More information

OUTPATIENT SERVICES CONTRACT and DISCLOSURE STATEMENT

OUTPATIENT SERVICES CONTRACT and DISCLOSURE STATEMENT OUTPATIENT SERVICES CONTRACT and DISCLOSURE STATEMENT Welcome to Northwest Neurobehavioral Institute (NNI). This document contains important information about our professional services and business policies.

More information

Client Information and Policy Statement

Client Information and Policy Statement Page 1 Page 2 Page 3 Client Information and Policy Statement I have compiled a summary of your rights and my responsibilities some of which are dictated by the State of Colorado. Please read them carefully

More information

LISA R. HERRICK, PH.D. Ph. 703-847-5793 Fx. 703-847-5791 www.lisaherrick.com

LISA R. HERRICK, PH.D. Ph. 703-847-5793 Fx. 703-847-5791 www.lisaherrick.com LISA R. HERRICK, PH.D. Ph. 703-847-5793 Fx. 703-847-5791 www.lisaherrick.com COLLABORATIVE DIVORCE MENTAL HEALTH PROFESSIONAL CLIENT AGREEMENT AND INFORMED CONSENT The Collaborative Divorce Process is

More information

Client Information Packet

Client Information Packet Phone: 303-569-4588 Office locations: Email: tony@equinoxcounselingllc.com Highlands Ranch Medical Plaza II: 9331 South Colorado Blvd., Suite 60 Website: www.equinoxcounselingllc.com Highlands Ranch, CO

More information

Counseling Intake Form (Each person attending therapy should complete a form)

Counseling Intake Form (Each person attending therapy should complete a form) Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay

More information

ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET

ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET COLLABORATIVE DIVORCE ENGAGEMENT AGREEMENT DIVORCE COACH This document contains important

More information

Nichol A. Moses, Psy.D., NCSP

Nichol A. Moses, Psy.D., NCSP PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to

More information

Bert Epstein, Psy.D.

Bert Epstein, Psy.D. Bert Epstein, Psy.D. 159 Kentucky Street Suite 3 Petaluma, CA 94952 707 242-1989 bert@drbertepstein.com CA License PSY 21404 Office Policies & Agreement for Psychotherapy Services Welcome. Your first visit

More information

Brenda Diller, MHR, CHT, HTP www.brendadiller.com Brenda@BrendaDiller.com BrendaDiller@hipaamail.us Office: 970-422-6102 Secure Fax: 970-422-7096

Brenda Diller, MHR, CHT, HTP www.brendadiller.com Brenda@BrendaDiller.com BrendaDiller@hipaamail.us Office: 970-422-6102 Secure Fax: 970-422-7096 Brenda Diller, MHR, CHT, HTP www.brendadiller.com Brenda@BrendaDiller.com BrendaDiller@hipaamail.us Office: 970-422-6102 Secure Fax: 970-422-7096 Durango Office: Colorado Springs Office: 150 E 9 th Street,

More information

House of Abba Counseling Center LLC. 9403 Hwy 707 S. Myrtle Beach, SC 29588 843-353-6216 Rev. Angel Onley-Livingston, M.A., LPCI

House of Abba Counseling Center LLC. 9403 Hwy 707 S. Myrtle Beach, SC 29588 843-353-6216 Rev. Angel Onley-Livingston, M.A., LPCI Psychotherapy Services Agreement with Angel Onley-Livingston Notice of Policies and Practices to Protect the Privacy of your Health Information This document contains important information about our professional

More information

TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452

TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 Dorothy B. Brown, Ph.D. Anne Davidge, Ph.D. Dennis J. Rog, Ed.D. Licensed

More information

Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108

Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108 Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108 COUNSELOR-CLIENT SERVICE AGREEMENT Welcome to my practice. This document

More information

Dr. Beth Gadomski Psychologist, CA License PSY 23658

Dr. Beth Gadomski Psychologist, CA License PSY 23658 page 1 of 7 Welcome to my practice. I look forward to our work together. You may have many questions as you begin work with a psychologist who is new to you. In an effort to answer some of those questions,

More information

PSYCHOLOGIST-CLIENT CONTRACT FOR INDIVIDUAL THERAPY

PSYCHOLOGIST-CLIENT CONTRACT FOR INDIVIDUAL THERAPY Sumer N. Ledet, Ph.D. Licensed Clinical Psychologist #1157 214 S. Burnside Ave., Ste. 203, Gonzales, LA 70737 Info@sumerledet.com http://www.sumerledet.com 225-647-5500 (office) 225-647-5507 (fax) PSYCHOLOGIST-CLIENT

More information

Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT

Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important

More information

Andrew Elman LPC ATR PROFESSIONAL DISCLOSURE STATEMENT

Andrew Elman LPC ATR PROFESSIONAL DISCLOSURE STATEMENT Personal counseling is conducted in various ways, depending on the counselor. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship.

More information

Amy Davis, M A, L P C

Amy Davis, M A, L P C Date: Referred by: May they be contacted to acknowledge your arrival? Yes No Client Information Name: Home Phone: Address: Cell Phone: City: State: Zip: Email: Date of Birth: / / School Name: Grade: School

More information

LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062

LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 PHONE: 847.497.8378 LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 Intake Form Date of Intake: Caller: DRLEIGHWEISZ.COM Referral Source: May I thank referral

More information

Disclosure Statement & Policies

Disclosure Statement & Policies - Medicaid Disclosure Statement & Policies Caitlin Kozicki LLC 7220 W. Jefferson Ave., Ste 218 Lakewood, CO 80235 5661 S. Curtice St. Littleton, CO 80120 303-957-6504 Ckozicki98@gmail.com This disclosure

More information

Informed Consent for Therapy Services Adult PSYCHOLOGIST-CLIENT SERVICE AGREEMENT

Informed Consent for Therapy Services Adult PSYCHOLOGIST-CLIENT SERVICE AGREEMENT Serenity Through Enrichment Psychological Services, LLC Nakia Perry-Goffney, PsyD, MA, LCP serenitythruenrichment@gmail.com 2915 Hunter Mill Road Suite 14 (571)723-2321 (office) Oakton, VA 22124 (571)319-8175

More information

Agreement for Therapy and Informed Consent

Agreement for Therapy and Informed Consent Agreement for Therapy and Informed Consent Welcome to the counseling program of St. Joseph Family Center. This Agreement for Therapy contains important information about our professional services and business

More information

PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER SERVICES

PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER SERVICES Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Sandra Mote, MS, CS, ARNP Patient Name (please print): Welcome to the psychotherapy and psychiatric

More information

Disclosure Statement

Disclosure Statement Denver Christian School K-12 Counseling Center 3898 S Teller Street Lakewood, CO 80235 1. COUNSELOR INFORMATION Disclosure Statement The following is a disclosure statement for the counseling department

More information

Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents

Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents PATIENT INFORMATION BROCHURE, CONTRACT & CONSENT FORM PSYCHOLOGICAL

More information

Kristin Reiners, MA, LPC-S, RPT, NCC Policies and Procedures

Kristin Reiners, MA, LPC-S, RPT, NCC Policies and Procedures Kristin Reiners, MA, LPC-S, RPT, NCC Policies and Procedures Missed Appointments/Cancellations First and foremost if you need to cancel an appointment and/or reschedule it must be done 24 hours in advance

More information

Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No

Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No : Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

Align Counseling. Shelly Hummel, LMFT. Informed Consent for Therapy Services THERAPIST-CLIENT SERVICE AGREEMENT

Align Counseling. Shelly Hummel, LMFT. Informed Consent for Therapy Services THERAPIST-CLIENT SERVICE AGREEMENT Align Counseling Shelly Hummel, LMFT Informed Consent for Therapy Services THERAPIST-CLIENT SERVICE AGREEMENT Welcome to my practice. This document contains important information about my professional

More information

Peaceful Path Counseling, LLC Amy Kay, LPC

Peaceful Path Counseling, LLC Amy Kay, LPC Revision VII, Effective January 15, 2015 Please Keep This for Your Records INTRODUCTION Welcome to my counseling practice. The decision to pursue counseling is an important one, often filled with questions.

More information

AGREEMENT FOR SERVICE / INFORMED CONSENT

AGREEMENT FOR SERVICE / INFORMED CONSENT Introduction Laura Bosworth, MFT, MS Counseling Licensed Marriage and Family Therapist License Number MFC 53156 12881 Knott St., #109, Garden Grove, CA 92841 562-716-3461 www.laurabosworthmft.com AGREEMENT

More information

Understanding Psychological Assessment and Informed Consent

Understanding Psychological Assessment and Informed Consent Understanding Psychological Assessment and Informed Consent You have taken the first step to feel more successful and empowered in your life by choosing to participate in a Psychological Assessment. Thank

More information

1 490 Sun Valley Drive Suite 205 Roswell, GA 30076 Tel: 404-735-1857

1 490 Sun Valley Drive Suite 205 Roswell, GA 30076 Tel: 404-735-1857 1 PROFESSIONAL DISCLOSURE and INFORMED CONSENT Welcome! I am pleased that you have decided to embark on this brave journey toward growth and healing. I m honored to walk alongside you. It s important that

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

CLIENT QUESTIONNAIRE

CLIENT QUESTIONNAIRE Leland E. McHatton, MFT Marriage Family Therapist 1430 East Avenue, Suite 4C 530.566.1212 Chico, California 95926 CLIENT QUESTIONNAIRE Client s Name: Spouse s or Parent s Name: Date of Birth: Date of Birth:

More information

Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006

Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 CELL (937) 684-7746 PLEASE USE THIS NUMBER TO SCHEDULE OR CHANGE APPOINTMENTS INFORMED CONSENT FOR TREATMENT

More information

One Day at a Time Counseling LLC

One Day at a Time Counseling LLC One Day at a Time Counseling LLC PSYCHOTHERAPY DISCLOSURE STATEMENT ABOUT MY PSYCHOTHERAPIST: 1. Angelina R. Cordova M.A. Ed, Doctoral Candidate LMFT, ACS, CACIII, RPT-S, CFI, NCPM 8000 E. Prentice Ave.

More information

Heather Gowin, MA, LPC

Heather Gowin, MA, LPC MANDATORY DISCLOSURE STATEMENT Name: DOB: Date: In accordance with Colorado State Law, the following information is provided to all persons entering or considering entering psychotherapy. I am a Licensed

More information

Melanie Bierenbaum, Psy.D. Licensed Psychologist 3040 E. Cactus Rd, Suite A Phoenix, AZ 85032 Office: 602-769-2773

Melanie Bierenbaum, Psy.D. Licensed Psychologist 3040 E. Cactus Rd, Suite A Phoenix, AZ 85032 Office: 602-769-2773 Service Agreement and Treatment Consent Welcome and thank you for choosing to work with Dr. Bierenbaum. This document contains important information about professional services, the psychologist-patient

More information

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478

More information

Mindful Health Advantage, LLC

Mindful Health Advantage, LLC 8015 West Alameda Ave., Ste 230, Lakewood, CO 80226 - - - CLIENT ADDRESS, CONTACT & FUNDING INFORMATION - - { CLIENT INFORMATION } Last Name First Name M.I. Date of Birth Ethnicity How did you hear about

More information

Amanda G. Johnson, LPC

Amanda G. Johnson, LPC Child Personal Information Child s Name: Date: Age: DOB: / / Gender: M F Race: Address: Apt: City: State: Zip Code: Father s Name: Date of Birth: / / Age Father s Occupation: Phone Number: Mother s Name:

More information