Forms

For new counseling clients, please print the following forms, fill them out as needed, and bring them with you to your first session.

The Notice of Privacy Practices does not need to be brought in with you, but we are required to give it to you and you need to sign that you reviewed it in the appropriate place on the Therapeutic Contract.

Therapeutic Contract

Sliding Scale Form

Intake Form

Notice of Privacy Practices

If you are the parent and your minor child is the new client, please also print and fill out this form:

Consent to Treat a Minor

For new clients of Susie Loomis, M.A., Family Life Educator/ Mentor, please print the following forms, fill them out as needed, and bring them with you to your first session.

Family Life Education Agreement

Sliding Scale Form

Additional forms your therapist may ask you to print and complete as needed:

Consent to Release Records

Videotaping Consent Form