If you're a new client, please complete the following forms and bring them to your first therapy session. With each form please fill out and mail back or fax or scan each form back to me at the following numbers:
MAIL: 26862 Woodward Ave. Suite 102, Royal Oak, MI 48067
FAX: 248-398-9456
SCAN TO: [email protected]
- Intake Form
- Passionate Love Scale Form
- Hypersexual Behavior Form
- Sexual Information Questionnaire
- Love Addiction Test
- Sternberg Relationship Questionnaire
- Release of Information
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:
Note: To download Adobe Acrobat Reader for free, Click here.
Confidentiality & Privacy Policy
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
Exceptions include:
- Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
- If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
- If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
