Intake Forms

Notice of Privacy Practices: The Notice of Privacy Practices describes how any protected health information (PHI) may be used and disclosed and your rights regarding it. NOTE: You do not need to send this with your intake paperwork.

Good Faith Estimate Notice: As part of the 2022 No Surprises Act, this notice informs clients who do not have insurance or choose not to use their insurance of their right to receive a Good Faith Estimate (GFE), an estimate intended to provide more transparency about the potential costs of services, to prevent unanticipated 'surprise' bills or costs. The GFE is just an estimate, and not a binding contract. 

Authorization for Release of Confidential Information: In order for me to be able to share/provide confidential information with a third party (aside from several circumstances that legally permit the sharing of confidential information such as mandated reporting), I will first need you to complete, sign and return an authorization for the release of confidential information.

Informed Consent for Brainspotting and EMDR: If choosing to pursue Brainspotting and/or EMDR treatment, and if deemed clinically appropriate for your situation, please read carefully, initial, complete, sign and return the informed consent below. 

Private-Pay (Medicare Opt-Out) Medical Services Contract: Because I am not connected to Medicare and am private-pay only, if you are a Medicare beneficiary and  wish to continue and consent to treatment with me (meaning paying out-of-pocket for any and all therapy services with me, and not using your Medicare benefits for those services), please read carefully, complete, sign and return the private services contract below.