Forms/Portal

Client Portal

Here you can schedule, cancel, or request a change to your appointment.

This is where you will log in for telehealth/virtual appointments.

Here is where you will access your initial paperwork to complete before our first appointment.

Don’t worry! It is HIPAA protected, confidential, secure.

Here is the paperwork that should be completed at least 24 hours PRIOR to your intake appointment.

I know it is a lot of paperwork and I understand that it can be overwhelming.

Your health and safety is very important, and I need to collect a lot of information to get the full picture of what is going on with you clinically.

Having some of the basic information collected, insurance and billing information entered, and forms signed, allows more time to get to know each other at your first visit.

Please let me know if you have any questions or concerns about completing paperwork.

Client History Form—Details of why you are coming in for therapy.
*You will need to complete this and send it back.

Client Contacts Form—Contact information for your emergency contacts, family, physician.

Client Information Form—Your basic demographic information, address, phone, etc.

Client Insurance Form—If you do not have insurance or you are choosing not to use your insurance, you will need to click the box to opt out. If you are using insurance, you will enter all of your policy information here.
*Signature required*

Payment Authorization—This is where credit card information is entered into my secure system. Once entered, I only see the last 4 digits of your card. I require a card to be kept on file.
*Signature required*

Consent for Services—This form explains the risks and benefits of treatment, policies, fees, and you will sign to consent to be treated.
*Signature required*

Notice of Privacy Practices—HIPAA information that you need to review and sign.
*Signature required*

Release of Information (ROI)—This is an optional form allowing me to share information of your choosing with another person or provider. This could be your physician, psychiatrist/nurse practitioner, or employer/school (accommodations letters).

I will not share information without a release, unless it is an emergency (you are missing, you are a danger to yourself or others) or required by law (Tarasoff Duty to Warn-you are going to hurt someone else, Mandated Reporting-child abuse or neglect).

You will be aware of and copied on anything that is shared.
*Signature required*

Assessments:

ACE—This is an assessment form to measure difficult experiences

ASRS-v1.1—This is an assessment form to measure attention and concentration

GAD-7—This is an assessment form to measure anxiety

PCL-5—This is an assessment form to measure trauma

PHQ-9—This is an assessment form to measure depression