Forms

Good Faith Estimate of Psychotherapy Services

A Good Faith Estimate of anticipated psychotherapy costs is provided to clients in your Welcome Email. The estimate is based on an initial course of approximately 8–10 sessions and is intended to help you understand the anticipated cost of services.

Your actual number of sessions and total cost may vary based on your individual or minor child’s treatment needs.

Intake Form – Adult

Adult Self-Assessment

Consent for Clinical Treatment

Notice of Privacy Practices

Intake Form – Minor

Minor Self-Assessment

Agreement for Minor Children

Consent for Clinical Treatment

Notice of Privacy Practices

If you need to authorize your clinician to have access to give or receive your health information, Authorization to Release Information

Church Assistance Program – Authorization Form

Church Assistance Program – Release Form