Karie Thulon Klim, MA, LMFT, CBS
Psychotherapy & Biofeedback Stress-Relief Services
(707) 888-0106

Forms

Dear Prospective Client,

The following forms are requested of all new clients. The forms are interactive for your word processing convenience.  If you are a psychotherapy client, please note relevant forms below in the left column. Biofeedback clients, there are three (3) forms only on the right side of the page. Bring forms on this page with you to your consultation*  You are welcome to call me at (707) 888-0106 or email me (
karie@karieklim.com
) if you have questions. 

I look forward to meeting with you soon.

Very best wishes,

Karie


*PLEASE DO NOT EMAIL OR TEXT CONFIDENTIAL OR VITAL STATISTICAL INFORMATION. 


PSYCHOTHERAPY NEW CLIENT FORMS

Most forms are interactive.  Please download, read, complete requested information, and sign the following documents and bring to the first appointment:

Download Forms

Age 5 - 17
Initial Child & Adolescent History & Intake
Consent to Treat a Minor (Ages 5-12)
Consent to Treat an Adolescent (Ages 13-17)
For Foster, Grandparents, and Other Caregivers: Caregiver Authorization
If Applicable: No Harm, No Suicide, Crisis Plan
If Applicable: Medications Record
If Applicable: Credit Card Processing Convenience Informed Consent

Age 18+
Adult Initial History & Client Intake
Informed Consent for Treatment
If Applicable: No Harm, No Suicide, Crisis Plan
If Applicable: Medications Record
If Applicable: Credit Card Processing Convenience Informed Consent

All Clients with Insurance:
Notice of Privacy Practices (HIPAA)
Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

Confidentiality Agreements
Authorization to Release Confidential Information
Authorization to Exchange Confidential Information


 
BIOFEEDBACK NEW
CLIENT FORMS

New clients, please download, read, and sign Policies & Procedures and the Informed Consent. Download the Wellness Suggestions and follow the instructions for preparing for and taking care of yourself following your sessions.

 
 
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