Forms

Before you come for your first session, it will be helpful for you to complete the following forms and bring them with you to your first session. If you cannot print or complete these forms before coming to the session, please arrive 30 minutes early in order to complete them there.

If you are an adult seeking individual counseling, you will need to fill out the following:

• Adult Intake
• Consent to Treatment
• Notice of Privacy--HIPPA

If you are two adults seeking couples counseling, you will both need to fill out the following forms:

• Adult Intake
• Consent to Treatment
• Notice of Privacy--HIPPA

If you are an adult seeking counseling for a child under the age of 13, you will need to fill out the following forms:

• Child Intake Form
• Child Behavioral Checklist
• Consent to Treatment
• Notice of Privacy--HIPPA

If you are an adult seeking counseling for a child under the age of 13 from a divorced home, you will need to fill out the following forms:

• Child Intake Form
• Child Behavioral Checklist
• Consent to Treatment
• Custody Form and copy of divorce decree
• Notice of Privacy--HIPPA

If you are an adult seeking counseling for an adolescent, you and the adolescent will need to fill out the following forms:

• Parent of Adolescent Intake Form (completed by the adult)
• Adolescent Intake (completed by the adolescent)
• Adolescent Behavioral Checklist (completed by the parent)
• Adolescent Behavioral Checklist (completed by the adolescent)
• Consent to Treatment
• Notice of Privacy--HIPPA

If you are an adult seeking counseling for an adolescent from a divorced home, you and the adolescent need to fill out the following forms:

• Parent of Adolescent Intake Form (completed by the adult)
• Adolescent Intake (completed by the adolescent)
• Adolescent Behavioral Checklist (completed by the parent)
• Adolescent Behavioral Checklist (completed by the adolescent)
• Consent to Treatment
• Notice of Privacy—HIPPA
• Custody Form and copy of divorce decree

If you are an adult seeking psychiatric services, you need to fill out the following:

• Adult intake
• Dr. Kemp’s Consent for Treatment
• Notice of Privacy—HIPPA

If you are seeking psychiatric services for a child or adolescent, you need to fill out the following forms:

• Adult intake
• Child’s intake (completed by the parent)
• Adolescent intake (completed by the adolescent)
• Dr. Kemp’s Consent for Treatment
• Notice of Privacy--HIPPA

If you are seeking psychiatric services for a child or adolescent from a divorced home, you need to fill out the following forms:

• Adult intake
• Child’s intake (completed by the parent) OR Adolescent intake (completed by the adolescent)
• Dr. Kemp’s Consent for Treatment
• Notice of Privacy—HIPPA
• Custody Form and copy of divorce decree

*** You will need Adobe Acrobat Reader to view and print forms ***