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Forms

Use these forms to get started! Please print and return them to me in-person. I cannot guarantee your email is secure and will protect your privacy.

Directions - Directions to my office or you can use Google Maps

Notice of Privacy Practices - My HIPAA Authorization that protects your privacy

Informed Consent - Individual - Understanding care for new clients

Informed Consent - Couple & Family - Understanding care for new clients

Intake Form - Background information about you and / or your family

Financial Responsibility Statement - Outlines payment for services

Release of Information - Allows me to communicate with your other providers

Please note: Some web browsers will not save information you enter into PDF forms. Remember to print a copy on paper or "print to pdf" to save to your computer.

Selin E. Caka, MA, LMFTA