New Patient Form

If you are a new patient please read the following information and fill out the form below.


Limits of Confidentiality

Content of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent ofthe client or the client's legal guardian.

Noted exception are as follows:

Duty to Warn & Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health care professional is required to report this information to the appropriate social service and / or legal authorities.

Prenatal Exposure to Controlled Substances

Mental health Care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Minors / Guardianship

Parents or legal guardians of non-emancipated minor clients have the right to access the client's records.

Insurance Providers (when applicable)

Insurance companies and other third party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to, types of service, dates / times of service, diagnosis, treatment plan, description of impairments, progress of therapy, case notes and summaries.


Cancellation Policy

Due to the fact that your appointment is reserved specifically for you, it is required that any cancellation be done over 24 hours prior to the scheduled session. If you fail to cancel a scheduled appointment, we cannot use that time for another client. Consequently, you will be billed for the entire cost of the missed session. Exceptions are granted in cases of illness or emergencies. A bill will be mailed directly to all clients who do not show up for, or cancel an appointment.

Thank you in advance for your understanding and cooperation in this important matter.


Patient's Name *
Patient's Name
Patient's Date of Birth *
Patient's Date of Birth
Patient's Address *
Patient's Address
Parent's Name
Parent's Name
Fill this out if the patient is under 18.
Home Phone Number
Home Phone Number
Cell Phone Number
Cell Phone Number
Work Phone Number
Work Phone Number
Phone numbers OK to leave message
Please check which phone numbers are OK to leave a voicemail message on.
Limits of Confidentiality *
Cancellation Policy *