Intake Form - Individual

Disclosure Statement - Individual

HIPAA (Health Insurance Portability and Accountability Act) - Individual

Treatment Plan

Limits of Service and Assumption of Risks:

Like any treatment, therapy sessions carry risks and benefits. Therapy sessions can reduce distress, resolve specific issues or concerns, and improve relationships. Potential improvements cannot be guaranteed, as there are many variables that can interfere with or affect therapy. Discussing unpleasant feelings or situations that you may be experiencing or have experienced in the past are considered risks of therapy.


By law, everything we discuss during our working relationship is strictly confidential, including the fact that we are working together. I must have your, or (if applicable) your guardian’s, permission to talk to or release any information about you to anyone else. The following are exceptions:

Duty to Warn and Protect: if you disclose a plan or threaten to harm yourself, I as your therapist must notify your emergency contact and legal authorities. The same is true if you disclose wanting to harm another; I am obligated to warn the person of interest and report to legal authorities.

Child and Vulnerable Adult Abuse: If you disclose, or there is a suspicion of, abuse to children and vulnerable adults, I am obligated to report that to Child or Adult Protective Services and/or legal authorities.

Prenatal Exposure to Controlled Substances: I am obligated to report any admitted prenatal exposure to controlled substances that could be harmful to the mother or child.

Guardians with Minors: Legal guardians of non-emancipated minors have the right to access the records.

Insurance Companies: Insurance companies and other third-party payers are given information relating to services provided. Typically that may include: date, time and type of service; diagnosis and treatment plan and progress; description of impairment, case notes and summaries.

Communication via text and email:

Based on  HIPAA guidelines the following information is advised about the use of cell phones and emails. It is important for you to know the potential risks associated with confidentiality when using these devices. Confidentiality cannot be assured with the use of any form of communication through electronic media, including text messages. It is advised that you do not use these methods of communication to discuss therapeutic content. If you do send me an email with clinical content, I cannot be responsible for the confidentiality of the material shared. Any email I receive from you, and any responses sent to you, will be considered part of your clinical record

Scheduling and Cancellations:

Your appointment time is your time with me. I will give you advanced notice for planned vacations and other events, and would appreciate a similar courtesy in return. For any urgent or unplanned events, such as illness, I would appreciate a 24 hour notice prior to the appointment, otherwise, a full fee will be charged. Please keep in mind that insurance companies do not cover missed appointments and the full charge will be out-of-pocket. I appreciate your help in keeping my schedule efficient and timely.