Initial Paperwork:
First-time clients please print and fill out all relevant forms for the type of service you will be receiving and bring them to your first session.
Individual, Couples, and Family Clients
Please scroll down to see if any of the other forms would apply to you as well - for example, credit card authorization, sliding scale, minor form, and/or release of information.
- Client Intake Form
Please print, fill out as directed, and bring to your first session. EACH client over 15 years of age needs to fill out and sign their own separate Client Intake Form. Parents would fill out and sign all documents for children under 15 as well as the Minor Client form (found below) for any child under 18.
- Therapist Patient Services Agreement
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.
- Minor Clients
This form is for parents of minor children to acknowledge CO laws re: right to consent to treatment and access to records. Divorced parents with full or joint custody will need to sign and provide legal documentation of custody agreement with respect to each parent's right to make decisions about mental health treatment. Custody evaluations are not conducted at Center for Valued Living, PLLC; opinions about custody will not be provided by CVL staff. Note: Adolescents between 15-18 should fill out the above intake form for individual or group therapy and those forms do not require parent signature; however, they should be aware that parents can legally access their records until they turn 18.
Social Security Disability Evaluations
Additional Forms: These forms are not required but may be useful in advancing your treatment.
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.
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 she initially consults with them. Consultation with anyone other than the person or people in treatment cannot occur without this written consent.
This form is used to request a reduced fee for those who are experiencing economic hardship. More information about the Sliding Scale opportunity can be found on theFees and Payments page or within the applications themselves.
You will need
Adobe Acrobat Reader to view these PDF forms.
