(714) 725-7121 therapist@couplestlc.com

Below are several documents that need to be filled out before your first appointment.  Once filled out, please bring them with you or upload a scanned version using the link below. Click on the link to download each document.

Individual

For an individual therapy click on the image below to download the form. Once form is filled out, please upload it back on this site.

Couples

For a couples therapy click on the image below to download the form. Once form is filled out, please upload it back on this site.

Family

For a family therapy click on the image below to download the form. Once form is filled out, please upload it back on this site.

Intake Questionnaire

This document asks basic questions about your personal history and additional details about your family. Each client needs to fill out this form.

Informed Consent and Disclosure Statement

This document authorities me to work with you and provides detailed information about the therapy process.

No Secrets Policy

This document describes therapist’s current practice of managing client’s secrets when working with families and couples.

Confidentiality & Privacy Policy

The law protects the confidentiality between a client(s) and a therapist. The confidential information cannot be disclosed without a written permission. There are some exceptions.

Exceptions to confidentiality

1. Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.

2. If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.

3. If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.