Forms

  • Adult/Couples Client 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.

  • 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.

  • 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.

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 he/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 the Fees and Payments page or within the applications themselves.


You will need Adobe Acrobat Reader to view these PDF forms.

 

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