Forms

Please click on the forms below to download those we need to get started. Next to each form link are instructions
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Psychotherapy Intake Forms

Psychotherapy Practice Policies & Informed Consent: For individual psychotherapy clients. This form provides an overview of my practice policies.

Individual Intake Questionnaire: For all individual psychotherapy clients. This form gives you the chance to tell me about yourself, your history, and the issues you would like to address in therapy. Please download, complete it, and bring to our first visit.

Psychotherapy Symptom Checklist: For individual psychotherapy clients. This form helps us to understand symptoms you might be experiencing.

Couples Therapy Questionnaire: For couples only. This form gives each member of the couple the chance to tell me a bit about history and the issues each wishes to address in therapy. Please download and print two copies. Each member of the couple should fill out the form and bring to our first visit.

Neurofeedback Forms

Neurofeedback Practice Policies & Informed Consent: For clients seeking neurofeedback only. This form provides an overview of my practice policies.

Neurofeeback Intake Questionnaire: For clients seeking neurofeedback only. This questionnaire is intended to gather information about your history, presenting concerns, current life, and goals for neurofeedback.

Medicare Advanced Beneficiary Notice for Neurofeedback: For clients with Medicare who are seeking neurofeedback.

Neurofeedback Take Home Sheet: Aftercare for neurofeedback sessions.

Insurance Forms

Insurance Coverage Questionnaire: For all psychotherapy clients wishing to use their insurance benefits for psychotherapy. Please download this form and make sure to complete each section. The backside of the form is intended to guide you when you call your insurance carrier to verify your benefits.

Medi-Cal/Partnership Beacon Forms
If you have Medi-Cal Beacon, in addition to the above Insurance Coverage Questionnaire, the forms below are required.

Beacon Health Strategies Member Rights: For clients with Beacon Health Strategies insurance. Please download, complete it, and bring to our first visit.

Beacon Release of Information (Therapist and Primary Care): For clients with Beacon Health Strategies insurance. Please download, complete it, and bring to our first visit.

Beacon Release of Information (Therapist to Beacon): For clients with Beacon Health Strategies insurance. Please download, complete it, and bring to our first visit.

Beacon Release of Information (Beacon to Therapist): For clients with Beacon Health Strategies insurance. Please download, complete it, and bring to our first visit.

Beacon Treatment Plan Signature Page: For clients with Beacon Health Strategies insurance. Please download and bring to your first visit.

HIPAA Form

HIPAA Notice of Privacy PracticesFor all psychotherapy and neurofeedback clients. This required form informs you about my privacy practices. Please download, review, and keep for your records.

HIPAA Receipt of Privacy PracticesFor all psychotherapy and neurofeedback clients. This required form is verification that you received the HIPAA Notice of Privacy Practices. Please download, complete it, and bring to our first visit.

Release of Information Forms

Release of InformationFor all psychotherapy and neurofeedback clients. This form allows me to communicate with other healthcare providers (e.g., psychiatrists, doctors, nurses, case managers) who are a part of your healthcare team, and is required if you are using insurance benefits. Please download, complete it, and bring to our first visit.