Intake Forms

IMG-1097Statement of Informed Consent

This document describes some of the policies and procedures that I have developed as part of my psychotherapeutic practice. At the end of the document, you are asked to sign to indicate your understanding and agreement to counseling services under these conditions. Please read each point carefully, and be sure to ask about anything that may be unclear to you.

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Release of Information Form

To those receiving information under this authorization: This information has been disclosed to you from records whose confidentiality is protected by state and federal law (42 CFR Part 2, ORS 192.501, ORS 502.505, ORS 179.505). You are prohibited from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by these laws and regulations.

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Personal Disclosure Statement

Here is some additional information about my practice as required by the Oregon Revised Statutes and my professional board.

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Intake Info Form Blank (Adult)

This form is to be completed by client.

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Intake Info Form Blank (Child)

This form is to be completed by a parent.

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IMG-1101