AUTHORIZATION

CLIENT HISTORY

Child

Please read and sign the consent-disclosure form prior to your first appointment also review the HIPAA form.

Please complete the client history form and either email or print and bring to the initial consultation.

If you would like me to communicate with another provider, please complete this form to authorize the release of information.

Please click, print and complete all applicable forms and remember to bring them with you to your first appointment.

Carolina

Total

CONSENT & HIPAA