NEW CLIENTS - Kindly complete all the below INTAKE + HIPPA + MBT Credit Card Authorization Form.
Our practice is mindful that therapy may be of an urgent nature especially towards weekends and holidays. We are available to work with you! We ask that completed forms be in legible handwriting with complete and updated information for methods of payment. If TeleHealth (a remote session) is required please add Telemental Health Informed Consent form to your list.
VERY IMPORTANT - To limit wait times FORMS MUST BE SCANNED IN ADOBE PDF FORMAT in the correct order and sent to: [email protected] or Faxed to 561-621-3518. Please bring these forms with you to your first physical appointment.
- Client Intake Form
- Informed Consent for Counseling
- Privacy Policies Notice
- Office Policy and Services Agreement
* If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete the HIPPA Authorization form to release of psychotherapy information:
PAYMENT AUTHORIZATION FORMS
- Life Coaching Services Agreement
- Functional Nutrition and Lifestyle Coaching Services Agreement
- Spiritual and Mindfulness Coaching Services Agreement.
- Life Coaching CC Authorization Form
- Functional Nutrition and Lifestyle CC Authorization Form
- Spiritual and Mindfulness Coaching CC Authorization Form
Note: To download Adobe Acrobat Reader for free, Click here.
Mental Health Counseling