Adult - New Client Paperwork (Adults)

Client Information, Informed Consent,
HIPAA Agreement, and Payment Information

Please complete this form and click "submit" at the bottom.

Client Information

* Indicates required field

Full Name: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Email: *

Date of Birth: *

Age: *

Occupation (if applicable): *

Spouse's/Partner's Name: (if applicable) *

Emergency Contact Information (will ONLY be used in case of an emergency):

Emergency Contact's Name: *

Emergency Contact's Number *

If applicable, please provide your children's names and dates of birth:

Child 1: *

Date of Birth: *

Child 2: *

Date of Birth: *

Child 3: *

Date of Birth: *

Child 4: *

Date of Birth: *

Child 5: *

Date of Birth: *

In your own words, what would you say is the presenting problem? Why have you decided to seek therapy, and why at this particular time? *

Informed Consent, HIPAA Agreement, and Office Policies and Procedures

*To access a copy of the Informed Consent, HIPAA Agreement, and Office Policies and Procedures, click this link.

Informed Consent Signature

By signing below, you are stating that you have read and understood the Informed Consent document (linked above), you understand the rules of and limits to confidentiality, and you accept the above-mentioned policies, fees, and informed consent. If 18 or older, as an adult, you are signing for yourself (or as a representative for a minor). [If under the age of 18, as a minor, you are aware that a representative will also be signing for you.]

HIPAA Signature

By signing below, you are stating you have read the information regarding your Patient Privacy Notice (HIPAA) (linked above), and are aware you may request a copy at any time.

Have you read, understood, and agree to the Informed Consent Agreement? *

Yes

Have you read the HIPAA information and are aware you may request a copy at any time? *

Yes

Payment Information

Please enter the payment information of the form of payment you would like to use to pay for your therapy sessions:

Name on Card: *

Expiration Date: *

Card Number: *

Security Code: *

By your electronic signature of this form, you authorize charges to your card through Stripe for services rendered, and certify that you are an authorized user of this card. You also are stating that you are aware of and accept the office policies and current [as of 2025] service and processing fees.

This authorization will remain in effect until you notify Dr. Shannon Francom, LMFT-S & Associates of any changes in your account information or termination of this authorization.

Have you read, understood, and agree to this payment authorization? *

Yes

Signature *

Date *

Submit

New Client Paperwork (Adults)

Client Information

Informed Consent, HIPAA Agreement, and Office Policies and Procedures

Payment Information

Dr. Shannon Francom, LMFT-Sand Associates

Dr. Shannon Francom, LMFT-S
and Associates