Submit New Client Forms

The information entered into/submitted from this page will encrypted and can only be read by Dr. Smith.

Date

First Name

Last Name

1) New Client Form

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2) Client Contact for Therapy

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3) Confidentiality Agreement

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4) Teletherapy Consent Form

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5) Insurance Form (found on Insurance & Fees page of website) Please attach your completed Insurance questionnaire here.

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6) Insurance Card If possible, please attach a scanned copy of your insurance card (front and back).

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Your information will be encrypted.