Forms

Please print and complete, to the best of your ability, the following forms prior to your first appointment.  Be sure to bring them with you, or email completed documents to ELutringer@gmail.com.

ALL CLIENTS

IntakeHIPPASignature – This document has several spots that you need to initial.  It is your agreement that you understand your rights and responsibilities.

Rights and responsibilities HIPPA – There is nothing you need to fill out in this document, but please read it, it describes your rights and responsibilities for counseling.

ROI – please print one copy for each person you want the counselor to be able to contact/speak with.  Usually, one for your Doctor (PCP), one for your child’s school, and one for anyone else we might need to communicate with.

Treatment Plan SIGNATURE SHEET.pdf – This document gives your permission for us to create a treatment plan for you or your child.

ADULTS

Adult_intake_form – This form helps us to understand what issues you are dealing with, and other important information that will help us formulate the best course of treatment.

AdultContactInfo –  This contains your contact information

CHILDREN / ADOLESCENTS

Child Outcomes questionaire – This is a useful questionnaire to be completed by a parent or guardian, or the child themselves if they are old enough.  It can also be helpful to have your child’s teacher complete one.  We will complete one of these at the start of counseling, and complete it again roughly once per month to help identify if treatment is working and areas we need to focus on.

ChildAdol_Intake_form – This form helps us understand what issues your child is dealing with, and other important information that will help us formulate the best course of treatment

ChildAdolContactInfo – This contains your child’s contact information