Individuals ● Couples ● Families ● Children ● Teens

Forms

image1

Individual & Couples Counseling

Infertility-Referral Evaluation Clients

Individual & Couples Counseling

Once we have spoken over the phone, please print and bring these forms with you to your first scheduled appointment. 


  1. Disclosure Statement
  2. Client Information Form
  3. Credit Card Authorization Form

image2

Parents Bringing a Child

Infertility-Referral Evaluation Clients

Individual & Couples Counseling

 Please print and bring these forms with you to your first scheduled appointment.


  1. Disclosure Statement
  2. Parent-Family Client Information Form
  3. Credit Card Authorization Form

image3

Infertility-Referral Evaluation Clients

Infertility-Referral Evaluation Clients

Infertility-Referral Evaluation Clients

Clicking below leads you  to a brief letter from me about the evaluation process.


Once we have spoken  and have a scheduled appointment, please print and complete these required forms prior to your session.

  1. Disclosure Statement-Fertility Eval
  2. Release of Information & HIPAA Form
  3. Recip Information Form/Personal Background Form (complete one for each person)


For your records, below is a link to the HIPAA/Privacy Practices for my practice.