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Client Paperwork & Referral Form

If you would like me to coordinate care with another provider (for example, your psychiatrist/psychiatric nurse practitioner, primary care physician, previous therapist, etc.), complete this form to authorize release of your protected health information.

If you are a healthcare provider, family member, psychotherapist/social worker, college counselor, lawyer, or other individual who would like to make a referral for someone, please complete the following form and return it by fax, email, or regular mail (listed at the bottom of this page).


Note: To download Adobe Acrobat Reader for free, click here .

Helpful Forms

Click here to view and print forms for your appointment.

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