SPIRITHERAPY

Forms

All Clients

Please print, complete and sign the

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CLIENT PACKET

• Demographics Form

• Confidentiality Policy

• Treatment Fee Agreement OR

• Insurance Fee Agreement Form

• Adult Intake Form OR

• Child Intake Form

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Fee for Service form is for clients who are self-pay and will receive a receipt for services.

Insurance Fee Agreement form is for clients who will be using their insurance for payment.  

Any adjustments to fees and co-pay fees can be addressed when you come to the first appointment.

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READ ONLY 

No need to Print - Credentials and Treatment Agreement

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Please bring the completed forms to your first visit.  Completing the forms prior to your visit will enable us to have more time to talk during your first visit. You can also choose to complete the forms at the time of your visit.

OTHER FORMS

• Consent to Use Electronic Methods in Therapy

• Authorization to Release Information

• Authorization to Inspect Copy of Records

Divorce Coaching/Mediation Clients

Please print out and read the Coaching Contract. You can sign it after you have spoken with me and clarified any concerns you may have.

• Coaching Contract