Forms

Please take the time to select, download, read and complete the appropriate forms.The Notice of Privacy Practices gives you information on the confidentiality of your medical records and how your privacy and confidentiality is protected.The Informed Consent and Service Agreement is an important explanation of the nature and possible benefits of therapy, as well as a discussion of our office policies.All the forms can be opened and downloaded in PDF format using Adobe Reader. If you do not have Adobe Reader it can be downloaded free by clicking here: Adobe Reader

FORMS FOR ADULTS

Forms for All ADULT Clients

Application for Services (Bring completed form to your first office visit.)

Notice of Privacy Practices (For your information only.)

Acknowledgment of Receipt of Notice of Privacy Practices (Bring signed form to your first office visit.)  

About Insurance (For your information only.)

 

Forms for COUPLES

"No Secrets" Policy (Each partner reads and signs one copy of this form. Bring completed form to your first office visit.)

Couples Screening Form (Each partner completes their own copy of this form. Bring completed form to your first office visit.)

Couples Satisfaction Checklist (Each partner completes their own copy of this form. Bring completed form to your first office visit.)

 

Forms for Mat Chirman's adult clients

Mat's Adult Service Agreement and Informed Consent (For your information only.)

Acknowledgment of Receipt of Informed Consent (Bring signed form to your first office visit.)  
 

Forms for Kim Richard's adult clients

Kim's Adult Service Agreement and Informed Consent (For your information only.)

Acknowledgment of Receipt of Informed Consent (Bring signed form to your first office visit.)

 

Forms for Elise Thompson's adult clients

Elise's Adult Services Agreement and Informed Consent (For your information only.)

Acknowledgment of Receipt of Informed Consent (Bring signed form to your first office visit.)

 

FORMS FOR CHILDREN
 

Forms for All CHILD Clients

Application for Services (Bring completed form to your first office visit.)

Notice of Privacy Practices (For your information only.)

Acknowledgment of Receipt of Notice of Privacy Practices (Bring signed form to your first office visit.)

About Insurance (For your information only.)

Developmental Questionnaire (Bring completed form to your first office visit.)
 

 Forms for Mat Chirman's minor clients

Mat's Minor Service Agreement and Informed Consent
(For your information only.)

Acknowledgment of Receipt of Informed Consent (Bring signed form to your first office visit.)
 

Forms for Kim Richard's minor clients

Kim's Minor Service Agreement and Informed Consent (For your information only.)

Acknowledgment of Receipt of Informed Consent (Bring signed form to your first office visit.)

 

Forms for Elise Thompson's minor clients

Elise's Minor Service Agreement and Informed Consent (For your information only.)

Acknowledgment of Receipt of Informed Consent (Bring signed form to your first office visit.)