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Blue Mountains
Blue Mountains

Helpful Forms

If you're a new client, please print the following forms, complete them offline and bring them to your first therapy session and please bring your insurance card:

PDF Client Intake Form

PDF Client Confidentiality Form

PDF Cancellation Policy

PDF Patient Info Sheet

PDF Patient Contract

 New Patient Insurance Verification Form

PDF Secondary Insurance Form
(only complete this form if you have secondary insurance)

PDF HIPAA Authorization
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.) complete this form to authorize release of psychotherapy information.

Note: To download Adobe Acrobat Reader for free, click here.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.

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Helpful Forms

Click here to view and print forms for your appointment.