Forms for Clients

 

Check with your therapist first, as some use their own customized versions of forms.

Filling out forms ahead of time can be helpful because you don’t always have the information, like medication dosage or your doctor’s phone number, with you at your appointment.

If you have any questions about a certain part of the form, just leave it blank and bring it with you to your appointment – your therapist can help you figure it out.

Additionally, there is a Release of Information Form that can be used at any time to give your therapist the right to communicate with others (doctors, family members, etc.).

Consent for Counseling Form

This form explains confidentiality practices and allows you to consent to counseling. Please print, read, sign, and bring with you to your first session.

Client Intake Information Form

This form asks you for basic information such as address, phone number, and medical history. Please print, complete, sign, and bring with you to your first session.

Contra Costa Medi-Cal Consumer Information Form

This form is specifically for clients with Contra Costa Medi-Cal coverage. If you have this coverage, please print, complete, and bring with you to your first session.

Your Privacy Rights According to HIPAA

This statement explains your rights to privacy and how to request your records. This is an important information-only document. Please print and read prior to your first session.

Release of Information Form

This form lets you consent to releasing your information to third parties, such as doctors, social workers, attorneys, or family members. If you have concerns about completing the form, please contact your therapist for more information.

Using the Forms

All forms are provided in Adobe PDF format. If you do not already have the Adobe Reader installed, click here to download