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African American Couple

Practice Forms

If you are a new client, you will receive a welcome e-mail once you schedule your first appointment.  This e-mail will provide instructions on setting up your Therapy Portal.  While all forms will also be included in the e-mail, I am also including them here. Please complete the appropriate intake packet and other forms listed below and bring them to your first therapy session. If you are coming for couples therapy, both the client and the spouse need to also complete the Couples Counseling Assessment and Consent Forms. Please date all forms for the date of your initial appointment.

Adult Clients:

Adult Intake Packet

Adult Medical History

Adult History Questionnaire

Children and Adolescents (please download, print and complete both forms):

Child-Adolescent Intake Packet

Statement of Understanding Child Therapy

Additional Forms for Couple Counseling (complete both):
Note: The primary client needs to complete the adult intake forms above.  Both the client and spouse need to complete the forms below.

Couple Counseling Assessment

Couple Counseling Informed Consent


Coordination of Care:
If you would like me to coordinate care with another provider (for example, your psychiatrist, school, etc.), complete this form to authorize release of therapy information:

General Release of Information

Release to Primary Care Physician

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