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Forms

Welcome, and congratulations in taking the first step toward wellness and personal empowerment!  I look forward to beginning our work together.  Before your first visit, please print out and complete the forms below to bring with you to your appointment.

 

Adult Intake Packet

Please complete this new client paperwork if you are an adult age 18 and over.

Child Intake Packet

Please complete this new client paperwork for child and adolescent clients younger than 18 years of age.

Release of Information

If you would like me to coordinate care with another provider (for example: your physician, psychiatrist, your child’s school teacher, etc.) please also complete a Release of Information form and bring it with you to your first session.

Papeleo Inicial (en Español)

Por favor complete este papeleo inicial si usted es mayor de edad y ya hemos programado su primer cita.

Autorización de Información (en Español)

Si usted desea coordinar servicios con otro proveedor (por ejemplo: su médico, psiquiatra, la escuela de su hijo/maestra, etc.) complete este formulario de Divulgacion de Información y tráigalo a nuestra primera sesión.

562-372-6160

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©2017-2020 ELENA DASGUPTA-TSINIKAS, LCSW.