downloadable
forms

Client registration form

Complete this form when you register as a new client. This form asks for your contact information and other relevent information.

Privacy Practices

This notice describes how clinical information about you may be used and disclosed and how you can get access to this information.

Insurance Billing Form

If you choose to pay for therapy using a third party payer such as a community agency or insurance company, I will typically submit authorization and claim forms directly to them.

Statement of Informed Consent

It is required by law for me to provide you with this information sheet that outlines what you can expect from therapy, what laws govern counseling as well as my fees and payment schedule.

Symptoms Checklist

This form is to be completed by all clients at the start of therapy.

No Secrets Agreement

This form applies to couples only and addresses confidentiality boundaries

related to couples seeking counseling.

Couples Questionnaire

This form applies to couples only and need to be completed in the early stages of therapy.

Contact

© 2018 Dorota Parys, LCSW.

1193 Pearl Street

Eugene, OR 97401

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Cell: 541-515-3325

Tel: 541-343-1937

Fax: 541-343-5875

dora@doratherapy.com