If you're a new client, please complete the following forms and bring them to your first therapy session.
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:
If you will be participating in telemental health services, please initial and sign the following informed consent:
Note: To download Adobe Acrobat Reader for free, click here .
Privacy & Policy Attachment and Experiential Therapy, LLC
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
- Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
- If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
- If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.