For your convenience, our intake forms are available to print from the website. Choose the intake packet that is listed for your counselor and that is for the appropriate age bracket. For example, if you are seeing Jennifer and if the client is a child, print all forms from that section. Carefully read and complete the intake forms
IN BLACK INK
and bring them with you to your first appointment. Please bring all pages of the forms (not just the signature pages); we will be happy to give you copies of them if you wish. This will save a lot of time so we can make the best use of your first appointment!
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*For couples counseling, each partner needs to complete his or her own intake packet.
(Click on the intake packet that is listed for your counselor and that is for the appropriate age bracket. )
Jennifer's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Jennifer's Intake Packet for Children (Ages 6 through 17)
Patient Health Questionnaire - ages 12 and up only
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Jennifer's Intake Packet for Couples* Counseling
Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gottman Permission Form
Acknowledgment of Financial Responsibility
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gottman Permission Form
Acknowledgment of Financial Responsibility
Sarah's Intake Packet for Adults and Couples* (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Sarah's Intake Packet for Teens (Ages 15 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Emily’s Intake Packet for Adults and Couples* (Age 18 and older)
Patient Health Questionnaire
Personal Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Personal Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Emily’s Intake Packet for Children (Ages 8 through 17)
Patient Health Questionnaire – ages 12 and up only
Personal Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Personal Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
J'Nae's Intake Packet for Children and Adolescents (Ages 3 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Robyn's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Robyn's Intake Packet for Children and Adolescents (Ages 6 through 17)
Patient Health Questionnaire
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Antoine's Intake Packet for Adults (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Acknowledgement of Financial Responsibility
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Professional Disclosure Statement
Acknowledgement of Financial Responsibility
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Lauren's Intake Packet for Adults and Couples (Age 18 and older)
Patient Health Questionnaire
Professional Disclosure Statement
Consent for Audio Recording
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Professional Disclosure Statement
Consent for Audio Recording
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Lauren's Intake Packet for Children and Adolescents (Under 18)
Patient Health Questionnaire - Ages 12 and up only
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Consent for Audio Recording
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility
Consent for Audio Recording
Yoga Workshop Intake Packet
Patient Health Questionnaire
Professional Disclosure Statement
Group Confidentiality Statement
TBR Student Waiver
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Professional Disclosure Statement
Group Confidentiality Statement
TBR Student Waiver
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Parent Counseling Group Intake Packet (One Per family)
Adolescent DBT Skills Group
DBT Group ConsentPHI Consent
Notice of Privacy Practice
Credit Card Payment Form