Intake Forms for Therapy
If you’re a new client, you will need to read some terms of service, then fill out and sign the following forms. Please do not fill them out until you have been instructed to do so. You can fill them out in any of the following ways:
- Fill them out by hand in the office.
- Download them below and fill them out on the computer or by hand, then:
- Bring them to the office.
- Upload them here. (Currently you need a Google account to use this feature.)
- E-mail them to firstname.lastname@example.org.
Please note that e-mail is not a perfectly confidential means of communication. There is a chance that these files could be exposed to unknown third parties on the Internet. They may also be exposed to people in your home or, if you are using your work e-mail, your employer. Please take these facts into consideration before choosing this option. See Consent to Treatment form for more information.
- Fill the form out online here.
To read before signing:
Consent for Telemental Health Services (if you will be having online sessions)
To fill out and sign:
Click here for the online form, or download below:
(Note: do not open the file in your browser to fill it out – download and open it in Acrobat Reader before trying to fill it out.)
Additional Page for Telemental Health Services (if you will be having online sessions)
The following forms do not need to be filled out unless you are specifically asked to do so by your therapist:
In order for me to communicate with other relevant parties (for example, your psychiatrist, primary care physician, school guidance counselor, etc.), I will need you to complete and sign this form to authorize me to release your/your child’s information:
- Authorization for Release of Confidential Information
- Authorization for Release of Confidential Information of a Minor
Note: To download Adobe Acrobat Reader for free, click here.
A therapist is legally prohibited from disclosing any information about a client without that client’s explicit permission. The only exceptions are the therapist believes that the client is a danger to him/herself or to others, or if the therapist has a reasonable suspicion of abuse of a child under 18 years old or a vulnerable adult.
Please see the full notice of privacy practices here.
Personal Development Coaching
Raffi led an informal group which I attended along with a few classmates from Israel in the summer of 2010. We had just returned to New Jersey from studying in a one- to two-year fellowship abroad. Ra
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