Forms | Sunny Strasburg, LMFT

INTAKE FORMS

Please click each link and print all of the forms below, fill them out, and bring to your first therapy appointment.

REQUIRED: Please submit the online forms below
- PATIENT REGISTRATION
- SELF ASSESSMENT
- LIMITATIONS OF CONFIDENTIALITY
Click Links for PDF Files:

PATIENT REGISTRATION

Date
Date Format: MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Client Employer:
Referred by:
Primary Care Physician:
Full Name of Spouse:
Emergency Contact:*
Signature*
Client authorizes and agrees to psychotherapeutic treatment. Treatment modalities may include insight oriented, cognitive behavioral, attachment theory, Gottman Couples Method, EMDR, and/or other empirically based modalities.OFFICE BILLINGI authorize that I am responsible for the full payment of services provided.There will be a $25 payment for all returned checks. In the event your account goes to collections, there will be a 20% collection fee added to your balance.There is a 24 hour cancellation policy which requires that you cancel your appointment 24 hours in advance between the hours of 8:00 am and 4:00 pm Monday through Friday to avoid being charged for the missed appointment. In the case of missed appointments without prior cancellation, appointments will be held up to fifteen minutes into the appointment time before clients will be charged for the full appointment fee.

LIMITS OF CONFIDENTIALITY

Name
First Last
LIMITS OF CONFIDENTIALITY*
We are required to disclose confidential information if any of the following conditions exist: 1. You are a danger to yourself or others. 2. You seek treatment ot avoid detection or apprehension or enable anyone to commit a crime. 3. Your therapist was appointed by the courts to evaluate you. 4. Your contact with your therapist is for the purpose of determining sanity in a criminal proceeding. 5. Your contact is for the purpose of establishing your competence. 6. The contact is one in which your psychotherapist must file a report to a public employer or as to information required to be recorded in a public office, if such report or record is open to public inspection. 7. You are under the age of 16 years and are the victim of a crime.8.You are a minor and your psychotherapist suspects you are a victim of child abuse 9. You are a person over the age of 65 and your psychotherapist believes you are the victim of physical abuse. Your therapist may disclose information if you are the victim of emotional abuse. 10. You die and the communication is important to decide an issue concerning a deed or conveyance, will or other writing executed by you affecting as interest in property. 11. You file suit against your therapist for breach of duty or your therapist files suit against you. 12. You have filed against anyone and have claimed mental/emotional damages part of the suit. 13. You waive your rights to privilege or give consent to limited disclosure by your therapist. *If you have any questions about these limitations, please discuss them with your therapist
I am consenting to my (or my dependent) receiving outpatient treatment. Signature:
RELEASE OF INFORMATIONI authorize Sunny Strasburg, LMFT to contact my primary care physician. Signature:

“Songkeeper” by Sunny Strasburg and Martin Stensaas