Forms

Please complete the adult or minor version of the following two forms prior to your or your child’s initial session:

  • Agreement for Service (Adult) PDF
  • Patient Information (Adult) PDF Word
  • Agreement for Service (Minor) PDF
  • Patient Information (Minor) PDF Word

The Agreement for Service includes a Notice of Privacy Policies and a Social Media Policy.

There are three options for completing these forms:

  1. Print them out, making sure to sign the Agreement for Service, and bring the completed copies to your first session;
  2. Use email (jeff@jefftherapy.com) to send the completed documents to me after filling them out on a computer or scanning them; if you use this approach, you should encrypt the Patient Information form with a password because it includes confidential information; leave the password on my voice mail so that I can open the document;
  3. Arrive at least 15 minutes early and complete the forms in the waiting room; if you choose this approach, let me know so that I can leave a clipboard with the requisite forms in the magazine rack of the waiting room.

Two other forms are optional. First, some types of therapy profit from videotaping, but only with your consent. Use the following form for that purpose:

  • Consent for Videotaping- PDF

Second, in some cases it will be valuable, with your consent, to discuss your case with other professionals, such as your physician or psychiatrist. Use the adult or minor version of following form for that purpose:

  • Authorization for Release of Information (Adult) – PDF Word
  • Authorization for Release of Information (Minor) – PDF Word