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Initial Intake Forms to Print

Upon scheduling of an initial session, all intake documents will be sent to you to be completed electronically. You can then submit them electronically back to me through my electronic health record. If you are unable to complete the forms online or they do not arrive on time please print, complete, and bring these forms to your initial intake to expedite the process of checking in. Thank you!

1 

Demographics Form

Print Form

Please be sure to bring a copy of your license or ID, and the front and back of your insurance card to your first visit. Please complete this form in it's entirety. 

2

Client Services Agreement

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This form reviews the therapeutic relationship and expectations, confidentiality, services for minors, appointments and cancellations, fee schedule, insurance reimbursement, and contacting Lightship Family Counseling, LLC

3

Privacy Practices

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This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully and bring any questions to your first appointment. 

4

Informed Consent for In-Person Treatment

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This consent form reviews client expectations during the COVID 19 public health crisis. It reviews what I do to help mitigate risk for clients that want to attend sessions in person and what I ask of everyone who comes in here.

5

Informed Consent for Telehealth Treatment

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This consent form reviews the pros and cons of receiving telehealth services. This also reviews expectations regarding the receipt of telehealth services including a safe and secure environment, appropriate attire, being physically located in the State of Connecticut or State of Florida. 

6

Release of Information

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Please complete a release of information for your primary care physician, previous mental health provider, significant other who may be attending treatment with you (couples or family sessions), or your child's school (for clients attending school). If you do not want me to coordinate please fill out the form and do not check off permissions. 

7

Credit Card Authorization Form

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Please complete this form if you are authorizing Lightship Family Counseling, LLC to directly charge a card at the time of session or once insurance sends patient responsibility amount. 

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