Please place your name on the line of "Name of individual/client".
On the To line please place the name of the person this specific Authorization is intended for e.g., physician, spouse or other person coordinating care such as acupuncturist etc.
Initial on the lines that say Mental health information and Drug/alcohol diagnosis, treatment, or referral information. (This information is especially protected by law.)
]]>New Client Adult Intake Formshttp://www.barbaramassey.com/forms/2011/1/6/new-client-adult-intake-forms.htmlBarbara Massey2011-01-07T05:12:35Z2011-01-07T05:12:35ZPlease print both pages and bring to your first appointment or email to barbara@barbaramassey.com.
Filling out the form as completely as possible will give us more time to discuss your concerns.