Client Forms

Collaborative Divorce with Mental Health Professional Agreement

For testing only

Consent for In-Person Services During Covid-19 Public Health Crisis

Client Name*
First Last
Name of client or person acting as legal representative for the purposes of this agreement.
Client Email Address*

Email address of client or representative for purposes of this agreement.
Minor Name (if also applicable)
First Last
Client Relationship to Minor Child (if also applicable)
Name
This field is for validation purposes and should be left unchanged.

Client Intake Form

Contract for Mediation Services

Contract for Court-Related Services

Contract for Co-Parenting Counseling and Skill Building Sessions

Consent for Therapeutic Treatment

Consent for Minor Therapeutic Treatment

Client Name*
First Last
Client Email*
Minor Name:*
First Last
Additional Minor Names:
Please add the first and last names, one per line, for each additional minor covered by this agreement.
Client Relationship to Minor(s):*
Name
This field is for validation purposes and should be left unchanged.

Authorization to Release Confidential Information

Client Name*
First Last
Client Email*
Minor Name(s) and DOB (if also applicable)
One minor name and dob per line.
Maiden / Other Name
Client Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Source of Authority (if acting as legal representative of client)

Authorization for Teletherapy

Credit Card on File Policy

Client Name*
First Last
Credit Card Type*
- Amex
- Visa
- Mastercard
Credit Card Number*
Expiration Date*
CVC Code*
Zip Code*
Cardholder Name*
First Last
Cardholder Email*
If your credit card is declined two consecutive times, we will be requesting a retainer before proceeding with new appointments.*
- By checking this box I agree to the terms mentioned above
Comments
This field is for validation purposes and should be left unchanged.

Notice of Privacy

Client Name*
First Last
Name of client or person acting as legal representative for the purposes of this agreement.
Client Email Address*

Email address of client or representative for purposes of this agreement.
Client Date of Birth*
MM slash DD slash YYYY
Minor Name (if also applicable)
First Last
Client Relationship to Minor (if also applicable):
Minor Date of Birth (if also applicable):
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

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