Client Counseling Forms

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This page is under construction. There may be links that do not yet work.

Thank you for your interest in my counseling services.

I am now booking appointments for January of 2023.

All forms on this page are HIPAA-secure. Please note that you will need to log into your Google account to view these forms. This is a security measure. If you do not have a Google account, please be advised that you will need one to receive therapy services with my therapy practice. It is free to set up a Google account.

Use this form to start the therapy process. Please note that you will need to log into a Google account to view this form. This is a security measure. If you do not have a Google account, please be advised that you will need one to receive therapy services with my therapy practice. It is free to set up a Google account.

Complete this form during the intake process before you begin therapy. This form is not publicly available. I will grant you access once I receive your initial contact form.

Informed Consent Agreement

Complete this form during the intake process before you begin therapy. This form is not publicly available. I will grant you access once I receive your initial contact form.

Please complete this form before every session. This form is not publicly available. I will grant you access once I receive your initial contact form.

Request for Collateral Interview

This form is not publicly available. I will grant you access once I receive your initial contact form.

Complete this form if you want me to share any or all of your records with you or a third party, or if you want me to speak with someone other than you about your case. This form is not publicly available. I will grant you access once I receive your initial contact form.

Areas of Interest Checklist

Complete this form during the intake process to help inform your treatment plan. This form is not publicly available. I will grant you access once I receive your initial contact form.

Use this form to let me know when there's a change to your address, cell phone, home phone, work phone, or email address.

Request for Unsecured Communications

Use this form to request email, text, video, or phone communication over unsecured channels. Caution: While using unsecured technology may be quicker and more convenient, it could compromise your privacy and is not recommended. This form is not publicly available. I will grant you access once I receive your initial contact form.

Learning Reflection

Complete this assessment after a learning activity to share your perception of the activity. This form is not publicly available. I will grant you access once I receive your initial contact form.

Change of Appointment Request

Use this form when you need to reschedule an appointment. Please be mindful of the cancellation policy, which you can review on my therapy services and fees page.

Complete this form to verify that you are located in the state of Florida. At this time, I am licensed to provide therapy in the state of Florida only. This form is not publicly available. I will grant you access once I receive your initial contact form.

Complete this form if you are not the client but intend to be the financially responsible party paying for the client's therapy services. This form is not publicly available. You will be prompted to set up a free Jotform account to access it. Please do not complete this form unless the client has sent me a release of information to speak with you regarding their presence in treatment. If they have not, I will not respond to your form submission. HIPAA law does not permit me to acknowledge that someone is/is not a client unless I have a release from them.

Changes to emergency contact information

Records request

Request for non-secure records transmission

Treatment Plan Receipt Acknowledgement