If you would like me to coordinate care with another provider (for example, your child's pediatrician, school, psychiatrist, your own primary care physician, etc.), complete this form to authorize release of psychotherapy information:
For child clients, to be filled out by parent(s): Below is a Child Intake Questionnaire and a Demographic Information form that I would like you to print and bring to your first appointment.
Child Intake Questionnaire
Demographic Information (Child)
For adult clients, please fill out the Demographic Information form below and bring to your first appointment.
Demographic Information (Adult)
Note: To download Adobe Acrobat Reader for free, click here.