Forms for Your Visit

Please Print Out and Complete the Following Forms Prior to Your First Appointment.

Adult Intake Packet or a Child Intake Packet

Or individually:

  1. Practice Policies and Agreement
  2. Insurance Information Form
  3. Authorization to Obtain and Release Information Form
    1. Please print out and fill one out each for 
    • your primary care doctor or pediatrician
    • your therapist (if applicable)
    • anyone else you wish for me to communicate with, send, or receive records from (school, another healthcare provider or institution)
  4. Child / Adolescent Intake Form  OR  Adult Intake Form
  5. Please review my Notice of Privacy Practices

Additional Forms

Card on File for Payment
Vanderbilt ADHD Parent Rating Scale
Vanderbilt ADHD Teacher Rating Scale

Your privacy is of the utmost importance to me. In general, I do not keep physical records which are prone to theft and fire. In addition to physical security and shredding, I utilize several services that increase your privacy while still maintaining record keeping and communication requirements.