Forms

Please print and complete the following forms and bring them with you to the first session:

• Intake Wellness Client Self Report
• Client Demographic Information
• HIPAA – Client Intake Form
• Ivan Diller Psychotherapy Procedures
• HICFA 1500-90
• Credit Card Authorization Form

Please complete if there are other service providers that should be contacted for collaborative purposes, e.g. prescribing psychiatrist, school guidance counselor or social worker, etc.

• Authorization for Release of Confidential Information