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)
  

Adult Psychosocial Assessment Intake

Consent for Treatment (Child & Adult)

Assignment of Benefits

Teletherapy Consent

Child (Under Age 14) Psychosocial Assessment Intake

HIPAA Form

Glio Counseling Credit Card Agreement

Authorization to Disclose Information Form (Optional)

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