Kelly Bernstein, MS, LCDC, LPC - Compassion, Understanding, Healing


Forms

1.  Client Intake Form
                                  
 
 

2.  Informed Consent Form
 

 
 


3.  Authorization to Disclose Protected Health Information

 


4.  Adult Functional Assessment Tool
 
 
 

5.  Consent to Treat a Minor
 
 
 
 
6.  Child History Form
Child History.pdf (PDF — 76 KB)
 
 
 
 
7.  Child Characteristics Checklist
 
 
 
 
8.  Fees and Policies
 
 
 
9.  Credit Card Pre-Authorization