Required Forms

Please download and complete the following forms prior to your intake appointment.

New Client History and Contact Information: This document is needed in order to provide basic background information.

Confidentiality Agreement: This document contains important information about confidentiality and any mandated limits of confidentiality that may arise in psychotherapy.

HIPAA: please sign acknowledgment of receipt of HIPAA notice.

Policies and Procedures: This document contains important information about Susan's professional services and business practices.

Financial Agreement: This document contains important information about fees and agreements between client and therapist.

Medicare Opt-Out: This document contains information regarding therapist's non-participation in Medicare and must be signed.

Additional Forms if Needed

Authorization to Release and Share Information: This form must be completed and signed if you would like for Susan to speak to another person regarding your treatment. This may include a psychiatrist, another therapist, an attorney, a close family member, a medical professional, etc. With a firm commitment to confidentiality, Susan will not acknowledge anything about your treatment, including whether or not you are even in treatment, without authorization. *Exceptions in emergency or by order of the Court.

Consent to Treat a Minor: This form must be filled out by any parent or legal guardian who has legal custodial rights for a minor client before treatment can begin. Upon occasion, especially in cases where litigation is a concern, Susan reserves the right to request a copy of custodial documentation, and other pertinent documents, to be included in the client file.