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First Session Forms

Currently all sessions are being held via Telehealth.  We utilize a secure, HIPAA compliant audio/video platform to connect.  You can print these forms and scan to send to your counselor prior to your first session.  You will also need to send a copy of your photo ID (Driver's License, Passport or Military ID) and a copy of the front and back of your insurance card.  Please scan as one continuous document and send to:  LivelyTherapy@protonmail.com
intake_-_hipaa_form_livelytherapy.pdf
File Size: 158 kb
File Type: pdf
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new_intake_dec_2021.pdf
File Size: 934 kb
File Type: pdf
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intake_-_no_surprise_gfe.pdf
File Size: 160 kb
File Type: pdf
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intake_-optional_release_consent_of_records_to_3rd_party.pdf
File Size: 80 kb
File Type: pdf
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intake_-_emergency_contact.pdf
File Size: 111 kb
File Type: pdf
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