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Personal Information

Please fill out the following forms in preparation for your initial session.
Please select any of the following that apply to you:
Have you had counseling in the past?
Counselor you are hoping to speak with:
What is your preferred availability:

Office Policies

I desire to do everything within my professional capacity to be of service to you. In keeping with my desire to communicate clearly and directly with you, the following are statements of my policies. If you have any questions about them please feel free to discuss them with me. Otherwise, please sign and return one copy of the sheet. I encourage you to keep another other copy for future reference.

Sessions are normally 50 minutes in duration, and must be scheduled in advance. Scheduling an appointment is my commitment to reserve time for you. Therefore, cancellations must be at least 24 hours in advance or you will be charged a $75 missed session fee for this time, unless the cancellation was due to an emergency. 

I am committed to keeping everything you share with me completely confidential. Whatever you say or do during a psychotherapy session will not be shared with anyone else without your written permission. However, there are certain exceptions to this policy that I would like you to be aware of. First, if you are involved in certain kinds of litigation and inform the court of the services you have received for me, you may be waving your right to have your records remain confidential. This will need to be clarified with your attorney. Second, if you threaten to harm yourself or someone else, I am obligated to inform potential helpers or victims. Information would be divulge only under unusual circumstances where someone’s life appeared to be in danger. Third, if I have reason to suspect you are currently involved in child abuse or neglect, I am obligated by law to report this to the appropriate state agency. Fourth, if you are a minor, your parents or guardians must be informed of your progress. If they ask, however, I will not reveal specific details of our conversations without your permission.

I have read and except the above practices and policies.

Thanks for completing the form, it has been submitted for review!

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