Client Forms

To make the most of your first visit, download these forms to complete ahead of time.

Filling out forms ahead of time can be helpful because you don’t always have the information, like medication dosage or your doctor’s phone number, with you at your appointment.
If you have any questions about a certain part of the form, just leave it blank and bring it with you to your appointment – I can help you figure it out.
Note: there is also a Release of Information Form that can be used at any time to give me the right to communicate with others (doctors, family members, etc.).

All forms are provided in Adobe PDF format. If you do not already have the Adobe Reader installed, click here to download.

• Consent for Counseling Form  – This form explains confidentiality practices and allows you to consent to counseling. Please print, read, sign, and bring with you to your first session.

• Your Privacy Rights According to HIPAA – This statement explains your rights to privacy and how to request your records. This is an important information-only document. Please print and read prior to your first session.

• Client Information Sheet – This form asks you for basic information such as address, phone number, and medical history. Please print, complete, sign, and bring with you to your first session.

• Contra Costa Medi-Cal Consumer Information Form – This form is specifically for clients with Contra Costa Medi-Cal coverage. If you have this coverage, please print, complete, and bring with you to your first session.

• Release Of Information Form – This form lets you consent to releasing your information to third parties, such as doctors, social workers, attorneys, or family members. If you have concerns about completing the form, please contact me for more information.