Helpful Forms

PLEASE NOTE THAT ALL FORMS MAY BE UNDER REVISION FOR 2023

If you're a new client, please complete the following forms and bring them to your first therapy session.

• BioPsychoSocial Intake Form
• Electronic Payment Authorization
• COVID-19 Waiver
• Consent for Telehealth

If your first appointment is with Leilani, please complete and sign this form (RATES INCREASED 5% 1/1/2023):

• Leilani's CO Mandatory Disclosure Statement
• Leilani's WY Mandatory Disclosure Statement
• Leilani's Supervision Disclosure and Contract

If your first appointment is with Martina, please complete and sign this form:

• Martina's Mandatory Disclosure Statement

If your first appointment is with Vanessa, please complete and sign this form:

• Vanessa's Mandatory Disclosure Statement

If your first appointment is will Karen, please complete and sign this form:

• Karen's Mandatory Disclosure Statement

If your first appointment is will Martha, please complete and sign this form:

•  Martha's Mandatory Disclosure Statement

If your first appointment is will Amanda, please complete and sign this form:

• Amanda's Mandatory Disclosure Statement

If your first appointment is will Lindsey, please complete and sign this form:

• Lindsey's Mandatory Disclosure Statement

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

• Authorization to Disclose Information Form

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