Forms

Disclosure FormIn order to make your time with us as valuable as possible, you can review this disclosure form and are invited to print and sign it and bring it to your first visit.

Registration Form – You are also invited to please print and fill out this Registration Form and have it with you for your first visit.

  • Circumstances

    • Relationship Issues
    • Major Life Changes
    • Separation/Divorce Physical/Emotional Abuse
    • Sexual Abuse/AssaultTraumaParenting
    • Loss

    • Death/Dying

    • Sexual Issues

    • Difficultly Sleeping

    • Spiritual Crisis

    • Spiritual Development

  • Behaviors

    • Socially Withdrawn From Others
    • Avoidance, Aggression: emotional/verbal/physical
    • Compulsive or Obsessive use of: alcohol, drugs, food, T.V., sex, computer, shopping
    • Child/Adolescent Problems
    • Obsessive
    • Impulsive
    • Hyperactive
    • Distractibility
    • Self Harm
  • Emotions

    • Depression

    • Anxiety/Worry/Panic

    • Agitation/Anger/Frustration

    • Sadness/Despair

    • Grief

    • Hopelessness

    • Fear/Terror

    • Mood Swings

    • Anger

    • Shame/Guilt

    • Loneliness

  • Thoughts


    • Difficulty with concentration/attention

    • Recurrent/intrusive thoughts

    • I am worthless

    • I am always scared

    • I can’t do anything right

    • I’m not lovable

    • Everything is my fault

    • I’m alone

    • I’ll always feel this way

    • It will always be this way