Intake Forms

- Intake Form (general)
- Intake Form (Wenatchee)

The documents listed above are included to help clarify the nature of our relationship and what we can expect of each other. They also let you know about my background and training, my therapeutic approach, and the business aspects of my practice so that you can be an informed consumer of mental health services.

I am required by state law and professional standards to provide some of this information to each new client. Other information, I have learned over the years, simply helps a person like yourself arrive at the best possible fit between therapist and client. You are encouraged to be an active participant, deciding among treatment options and plans. That active participation begins now as you read and complete these forms. Completing them as fully as possible prior to our first session, including writing down any questions you may have and bringing them with you, will help us be
productive from the outset.

The above documents include:

• Provider Profile – including a photo and brief description of my professional background.
• Disclosure Statement/Office Policies– Information that state law requires that we provide and discuss with all new clients. There are two copies: one copy is for you to keep for your records; the other is for you to please sign, date and return to me for your file.
• Intake form – The front side is information necessary for our accounting purposes and/or to bill your insurance company. Be sure to indicate if you have secondary coverage in addition to your primary insurance. Please contact my billing specialist, Shelly DeRousseau at Gigibyte Medical Billing, 752-9569 before your appointment; she will assist you in determining your insurance benefits. The reverse side is information that will help me help you as effectively as possible. Please complete all items in as much detail as you can, even if some seem unrelated to your present concerns.