If you're a new client, please complete the following forms and bring them to your first therapy session. Let me know if you have any issues with printing ahead of your first session.
Note: To download Adobe Acrobat Reader for free, click here.
These individual forms are included in the above packet.
- Client Information Form
- Treatment Consent Form
- Privacy and HIPAA Form
- Payment Agreement Form
- Credit Card Authorization Form
- Checklist of Concerns
If you would like me to coordinate care with another provider (for example, your psychiatrist or primary care physician), or contact your employer, HR, or ADA compliance, complete this form to authorize release of psychotherapy information. This can always been done later on when you need it.
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
- Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
- If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
- If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not or cannot cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
Please call today (804) 366-1345 for an initial appointment and together we will discover how I can help you!
Original page content copyright © 2016 by Sandra L. Wiggins.