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Helpful Forms

If you are a new client, please complete the following forms and bring them to your first appointment.  My office is located in the three story, yellow office building in the Fitness 19 parking lot.  Take the elevator to the third floor and I am located in suite #303.  Please give yourself a few extra minutes to find the office suite.  Once you enter the waiting room, you can flip on the light switch labeled "Dr. Learn" to let me know that you have arrived.
 

Adult Forms (Please print/sign all 4 forms)

Adult Intake Form
Informed Consent for Treatment

Notice of Privacy Practices
Electronic Communication Policy


Adolescent Forms (Please print/sign all 5 forms)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information: Authorization to Disclose Information Form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Note: To download Adobe Acrobat Reader for free, click here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Helpful Forms

Click here to view and print forms for your appointment.

Click Here