NOTE: Please do NOT complete or send these intake forms unless you have had a free brief phone consultation with
Julie Trosin, LMFT verifying appropriateness for outpatient telehealth treatment and confirming mutually
to proceed and schedule an initial intake assessment appointment.
FOR NEW CLIENTS: Welcome! Please complete the following three forms:
Adult Intake (separate form per individual) AND Informed Consent AND Adult Checklist of Concerns
For convenience, you may mail the completed paperwork to
Julie Trosin, LMFT, P.O. Box 2133, Rancho Cordova, CA 95741
or email them to firstname.lastname@example.org.
* Please review the Notice of Privacy Practices provided below in Additional Forms & Notices to learn how any protected
health information (PHI) may be used and disclosed and your rights regarding it. You do not need to send this with your intake paperwork.
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.
FOR COUPLES and/or COLLATERALS: If beginning couples, marital and/or premarital counseling, please read and sign the following No Secrets Policy and email it with the rest of your initial intake appointment paperwork. If participating in collateral work, please read, sign and email the following Collateral Informed Consent prior to any shared sessions.
Copyright © 2018 Julie Trosin, LMFT - All Rights Reserved.