Forms

New clients: Please complete all forms below. Forms will be submitted through a secure, encrypted connection. Your privacy is our first priority.

Patient intake form

Informed consent for telehealth services

Consent for treatment and office policies

Consent for the release of confidential information

Confidentiality & Privacy Policy:

HIPAA regulations protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to any other person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm him/herself, I will make every effort to enlist their cooperation in ensuring their safety.  If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.

2345 Route 52, Suite F
Hopewell Junction, NY 12533
(914) 860-6762