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Senior Citizen Couple
Senior Citizen Couple

FORMS (please print forms and bring to your appointment)

 Please print out and fill out the forms

and bring them to your appointment

Forms filled out on-line do not get saved. 

If you're a new client or a caregiver establishing individual care, please complete the following forms and bring them to your first evaluation session.



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:

If you are a person LIVING with dementia please fill out The Initial Evallation Form (above) and please ask your family care partner to complete caregiver forms and bring them to your first evaluation session

Controlled Substances Agreement Form

Medical History, Care Coordination form
Symptom Monitoring form 
Medications Monitoring form
Sleep Monitoring form
Drinking Monitoring form
Exercise, Food Monitoring form
Consent for Neurofeedback form
Apapthy Evaluation Scale
Spiritual Health Assessment


Relationship Wants Worksheet 

Self-Care Worksheet

Relationship Fears Workseet
Note: To download Adobe Acrobat Reader for free, click here.

Schedule Appointment

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Helpful Forms

Click here to view and print forms for your appointment.

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