Below are the documents you will need for your first appointment. Please bring the necessary completed forms when you come for your first appointment. You may also submit them electronically.
Required Forms
Client Intake Form
Client Intake Signature Form
Client Insurance Form
Authorization for Credit Card Charges Form
Video Therapy Consent Form
Copies of Insurance Card (front & back) and Picture ID
Optional Forms
(print and complete if needed)
Information Release Consent Form
Adjusted Fee Application
Client Satisfaction Survey
Forms for Review
Therapy Disclosure Information Form
HIPAA Notice of Privacy Practices Form
Financial Policy and Fee Agreement
Counselor Disclosure Statements
C. Jane Osment, M.A.R., M.Div., LPC-S, MFT
Debra Carnosso, M.S.W., LISW-CP
Stacy Fraser, M.A., LPC
Michelle Estep, M.A., LPC
Insurance information can be found on the Counseling page.