Psychotherapy Forms

If you are interested in psychotherapy, I would appreciate you contacting me at 612-766-9255. After we have agreed to make an appointment, please print (on one side of the paper), read and complete the following forms. Please mail the originals and a copy of your insurance card into my office. If you're going to use insurance, please contact your insurance company to determine your coverage. Thank you.

Adult Forms

All Adult Forms


Adult Registration Form

Outpatient Services Contract

Adult Intake Questionaire

Data Privacy Form



Optional Forms

Credit Card Pre-Authorization Form

Private Information Release Form

Child Forms

All Child Forms


Outpatient Services Contract

Pediatric Psych New Patient Info

Consent for Treatment of a Minor (ages 5-12)

Data Privacy Form

Child/teen registration form



Teen Forms

All Teen Forms


Outpatient Services Contract

Pediatric Psych New Patient Info

Consent for Treatment of a Minor (ages 13-18)

Data Privacy Form

Child/teen registration form