Intake, Limits of Confidentiality, Consent

Please fill out the following Intake and Consent Form. The information provided by you here will be transmitted to my email address and will not be stored on any servers anywhere. This information is a part of your confidential file that is governed by the CRPO’s Client Record Keeping Standards of Practice.

Please complete the form below

Credit Card Charge Authorization

Optional Form

Fill out this form if you would like to have your Credit Card charged at the end of every session as a payment option. The fields in this form are for information gathering purposes only. Your card will not be charged at this time.