Forms

In addition to the forms provided on the Appointments page, you may find the following forms and documents helpful:

Authorization to Release Confidential Records and Information
This form provides permission so that I can share information with others who are involved in your care (e.g., physicians, psychiatrists, school personnel).

Agreement Form for Collaterals
Spouses, partners, and other family members who attend a client’s treatment sessions (most typically for couples therapy) need to sign a separate form that reviews policies related to their participation.

Schedule of Charges
This provides my charges for my services. I am an in-network provider for Blue Cross Blue Shield PPO; those clients are only responsible for their deductible, co-pay, or co-insurance according to their policies.

Recommended Psychiatrists
For those clients who wish to pursue medication, I recommend the following psychiatrists whose offices are nearby.