Forms for Intake Appointment

Please look for the type of therapy service you have been scheduled for in the intake appointment.  Please download all the forms, fill them out, and print them.  Bring all the listed intake forms to your intake appointment and provide them to your therapist at the beginning of your session.  We also wanted to provide you with a document that will help you ask the right questions should you consider contacting your health insurer for possible reimbursement.

 
  • Individual Adult Therapy

    (1)  Intake Form (Individual)

    (2)  Informed Consent Agreement

    (3)  HIPAA Privacy Notice (for you to keep)

    (4)  Credit Card Authorization Form 

  • Individual Child/Adolescent Therapy
     (under 12 years old)
  • Individual Adolescent Therapy

    (over 12 years old)

  • Couples Therapy

    (1)  Intake Form (one filled out by each partner)

    (2)  Informed Consent Agreement

    (3)  HIPAA Privacy Notice (for you to keep)

    (4)  Credit Card Authorization Form 

  • Co-parenting Therapy

    (1)  Intake Form (one filled out by each parent)

    (2)  Informed Consent Agreement

    (3)  HIPAA Privacy Notice (for you to keep)

    (4)  Credit Card Authorization Form 

  • Parent Child Interaction Therapy
  • Psychological Assessment and Testing

2577 Samaritan Drive, Suite 715

San Jose, CA 95124

408-962-9267 

info@talkawhile.org

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