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Licensed Psychologist - PSY23635  
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2006 Dwight Way, Suite 103
Berkeley, CA 94704
510.273.2497 (Voice & Fax)


Intake Form
You may complete and print this form to bring to your first appointment to save time
Informed Consent We will review this form together, but feel free to look it over before coming to meet with me.
Release of Information If you would like for me to release confidential information, or for others to provide confidential information to me, complete this form
HIPAA Information Information about the Health Insurance Portability and Accountability Act. We will also review this form together, and I will keep a signed copy in your file.
Assignment of Benefits If you are planning to use your insurance benefits for counseling, you will need to complete this form

All forms are in Adobe PDF Format.



Collaborative, empowering,

We will work together to help you realize your goals.