If you are new you will need to complete one of the following forms. You must have an appointment already scheduled with me prior to completing the relevant intake form and I cannot accept forms sent to me if you have not already arranged an appointment with me. If you are an adult getting services for yourself please complete the “Information and Informed Consent” form. If you are a parent seeking services for your child please complete the “Teen or Minor Information and Informed Consent” form.
Please print and complete this form before your first appointment if possible. You may return the form by email or in person at your first appointment If you cannot do the form ahead of time please arrive to your first appointment about 15 minutes early with your insurance information. I will need a copy of your insurance card if you would like to use your health insurance. Returning this form ahead of time can help us get started sooner and help us figure out your copay more quickly if applicable. Please note that your email is not encrypted and I cannot guarantee electronic confidentiality of any emails you send me.
The disclosure statement and fees is there for your convenience. Please be aware that most insurance companies do not pay 100% of the bill and you are responsible for the remainder of the cost.
Disclosure Statement & Fees THLPC
Information and Informed Consent
Minor Information and Informed Consent