NEW CLIENT FORMS

For Medicaid Clients Only

3. Authorization of Disclosure

Please enter the name of your primary care provider, OB/GYN, physician, or urgent care provider in the ‘Person/Agency/Company’ field. Our office will need to fax the provider a document related to consent for therapy.

• This assessment is required to assist Tanielle with developing individualized therapy goals. It follows the CBT model by exploring the relationship among thoughts, physical responses, emotional states, and inward or outward actions.