New Client Intake Packet
Everything I need before we meet, in one fillable PDF (7 pages):
- Client information
- Background questionnaire
- Informed consent and confidentiality
- Fees, payment, and superbill agreement
- Release of information (optional)
- Parent / guardian information for clients under 18
Release of Information
Use this form if you would like me to share information with, or receive information from, others such as a physician, another therapist, a school, an attorney, or a court. One form covers up to four people or organizations.
Download release form (PDF)How to complete the forms
Download and open
Open the PDF in Adobe Acrobat Reader (free) or Preview on a Mac. Most web browsers can fill it in too, but may not save your answers reliably.
Fill in and sign
Click into each box to type. Typing your full name in a signature box serves as your electronic signature. Answer only what you are comfortable sharing; we will go over everything together.
Save and return
Save the completed file and bring it to your first appointment, or email it to Archer@archermaness.com. You are also welcome to print the forms and bring a paper copy.
For clients under 18
A parent or legal guardian with authority to consent to treatment should complete and sign the forms. If parents are separated or divorced, please bring a copy of the current custody order to the first appointment.
A note about privacy
Regular email is not fully secure. If you would rather not send personal information by email, please print the completed forms and bring them to your first session.
Questions about the forms?
Send an email or call, and I will be glad to help.