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Blue Mountains
Blue Mountains

Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

  • Client Psychotherapy Intake Form (Adult OR Child)
  • Assignment of Benefits
  • Consent for Treatment
  • Credit Card Authorization (to keep on file for copay/coinsurance)
  • HIPAA Form

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form (Optional)

 

Consent for Treatment (Child & Adult) Adult Psychosocial Assessment Intake
Assignment of Benefits  Child (Under Age 14) Psychosocial Assessment Intake
Authorization to Disclose Information Form (Optional) HIPAA Form
Glio Counseling Credit Card Agreement  
   




Note: To download Adobe Acrobat Reader for free, click here.

 

 

 

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Helpful Forms

Click here to view and print forms for your appointment.

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