ConsI am an independent contractor with the Institute for Couple and Family Enhancement (ICFE) and the Information Forms and Consent forms for therapy services can be found by clicking the hyperlinks below.
If you are a new client*, please print and complete the following forms to bring with you for the first session:
Adult Client Information Form *
Consent for Communication*
Therapy Information and Consent to Treatment Form
Pre Authorized Billing/Credit Card Agreement Form
*Each adult attending therapy should complete a separate form.
If you are bringing a minor for therapy, please complete the following forms in addition to the forms needed for adults who will be attending with the minor.**
Minor Information Form
Minor Consent Form
**Please note that signatures affirm that you have the legal authority to consent for treatment of the minor named in the forms. If your legal guardianship is in any way directed by a court order, you will need to provide a copy of the order. You will also need to provide information on custody and guardianship arrangements, and, if applicable, inform the co-parent of the minor’s participation in therapy.
In compliance with the Health Insurance Portability and Accountability Act of 1996 the following is a copy of the Privacy Policies for your review. Please let me know if you have any questions about the management of private health information (PHI).
Notice of Privacy Practice
If you prefer to complete the forms in person, let me know and I can have the forms available to you in our waiting area. Please plan to come 15 minutes early to your appointment if you select to complete the forms in person before the session.