Helpful Forms

 

IMAG0322Please print and fill out the forms below. The information you provide will help me get to know you and your child and develop an appropriate treatment plan.

 

registration form

service agreement/informed consent

intake assessment (for children)

behavioral index (for children)

hypnotherapy questionnaire (for adults)

If you plan to have me consult and share information with another provider:

authorization to disclose information 

If you plan to use out of network insurance:

authorization for treatment and payment of medical bills

Bring the forms to your first appointment. I look forward to getting to know you and helping in any way I can!