New Client Paperwork (Adults)

Client Information, Informed Consent, and HIPAA Agreement
(for Adults)

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

* 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? *

RETURN to this page after clicking this link to access
the Informed Consent and HIPAA Agreement.

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

Signature *

Date *

Submit

New Client Paperwork

​RETURN to this page after clicking this link to accessthe Informed Consent and HIPAA Agreement.

Dr. Shannon Francom, LMFT-Sand Associates

RETURN to this page after clicking this link to access
the Informed Consent and HIPAA Agreement.

Dr. Shannon Francom, LMFT-S
and Associates