Forms

If you’re a new client, please complete the following forms and bring them to your first training and consultation session.
• Limits of Confidentiality/Training Session Cancellation Policy
• If you would like me to coordinate or collaborate with another human service agency,
school, or provider (for example, school social worker, CMH case coordinator, juvenile
division case worker, probation officer), complete this form to authorize release of
training and consultation session information.
Privacy Policy
• Confidentiality and Privacy Policy
• The law protects the relationship between a client and a Limited Licensed Behavior
Psychologist, and information can not be disclosed without written permission.

• Limits of Confidentiality/Therapy Cancellation Policy

Authorization to Disclose Information Form

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LOCATION

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Office Hours

Primary

Monday:

9:00 am-6:00 pm

Tuesday:

9:00 am-6:00 pm

Wednesday:

9:00 am-6:00 pm

Thursday:

9:00 am-6:00 pm

Friday:

9:00 am-6:00 pm

Saturday:

By Appointment

Sunday:

Closed