**Until at least May 4th, 2021, all appointments are via virtual therapy only. Please see the Virtual Therapy Forms Page for the correct intake paperwork and instructions.**

Adult/Couples Intake Form

Please print, fill out as directed, and bring to your first session. EACH client over 18 years of age needs to fill out and sign their own separate Client Intake Form.

• Adult Intake Form

Child Intake Form (under 18)

Please print, fill out as directed, and bring to your child's first session. Parents should sign for children under 18 years of age and clients between 15-17 may add their own signature for informed consent.

• Child Intake Form (under 18)

Additional Forms

These forms are not required but may be useful in advancing your treatment.

• Credit Card Authorization Form

If you would like to pay by credit card, you will need to fill out this form. You can pay via credit card once or on a continuous basis. You will need to fill out this form again only if you change the frequency of credit card payments or if the credit card information changes.

• Release of Information

By filling out this one-page form, you are authorizing Center for Valued Living, PLLC to consult with other people, whom you specifically select, about your treatment (e.g., physicians, lawyers, school personnel, family, etc.). You and your therapist would decide the nature of the information discussed with these other people before he/she initially consults with them. Consultation with anyone other than the person or people in treatment cannot occur without this written consent.

• Sliding Scale Form

If you do not have insurance and are interested in using a private pay sliding scale please fill out this form.

For Informational Purposes Only

• Practice Guidelines and Policies

FOR INFORMATIONAL PURPOSES ONLY. You may read online or print to read but you do not need to bring in or give to your therapist. We will review the information in this form verbally at the beginning of your first session.

• HIPAA Privacy Notice

FOR INFORMATIONAL PURPOSES ONLY. You may read online or print to read but you do not need to bring in or give to your therapist. We will review the information in this form verbally at the beginning of your first session.