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Below are forms we need prior to commencement of psychotherapy services.  Please read the description below the link to decide whether you need the specific form or not.  All forms require Adobe Reader which is available for free.  If you do not have it, you can download it here.

Client Information Sheet
REQUIRED:  Please download, fill out, print out the Client Information Sheet prior to your first appointment.  The information requested on this form include your name, address, your contact information as well emergency contact, and history of prior mental health services.

Client Agreement / Consent for Services
REQUIRED:  This form constitutes your agreement to receive services and is required prior to receiving services.  Please download and read it carefully.  If you agree to the terms described, please initial where indicated, fill out your name (or the name of the client and your name if the client is a minor, as well as your relationship to the minor), sign, and bring with you to your first session.

Authorization for Use or Disclosure of Protected Health Information
MAY NOT BE NECESSARY.  Your confidentiality is something we highly value.  However, there may be instances when we will need to speak to someone to obtain information.  This includes school administrators, doctors, and psychiatrists.  Also, if the services being provided will require other individuals to be present in session such as family members, we will need your written and signed authorization. The information we receive is subject to the same privacy rights detailed in our Notice of Privacy Practices and will not be disclosed without your prior written consent or as required or permitted by law.

This form need not be filled out at the time of your first appointment unless you are seeking family services involving one or more members.  In which case, each family member must download, fill out, print and sign this form.

Caregiver Authorization Affidavit
MAY NOT BE NECESSARY.  If you are seeking services for a minor who lives with you and you are not the biological or adoptive parent, we will need this form completed prior to commencement of services.
 

Please Note

Please Note: I currently am not accepting clients at this time. If you require attention, please visit ClinicalPsychotherapists.com or ModernFamilyLiving.com for listings of qualified therapists near you.

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Notice

1.  Where photos appear within this website, other than that of Franco E. Santos, such photos are of models and not of actual clients. (In compliance with B&P §651(b)(3)(B).)
2.  Each person is unique and so is each's life circumstances and needs.  The information found herein are provided as general description only and not meant to apply to every situation.  If you feel you or someone you know needs help, please contact Franco E. Santos.

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