Client Forms

Forms to be filled out before our first meeting

 

Please bring these forms to your first session. 

They will also be in the waiting room if you would prefer to fill them out there. 

In that case, please arrive 15 minutes early, since they do need to be completed before we begin. 

 

(You can fill this out on your computer, if you like, and then print it.  Please do not e-mail me for privacy reasons.)

Authorization to Release Confidential Information Form

 

New client informed consent -- please fill this out, read, sign, and bring to your first session. This form explains the therapy process.  If you have any questions, please feel free to ask them at your first session.

 

Adult History form -- ( For 18 years and older) Please fill out as complete as you can.  This will help us use our first session more productively, and may help clarify what your goals are for therapy.  If you are unsure about any of the questions, please feel free to discuss when you come into the office. 

Adolescent / child form- (For 17 years and younger) Please fill out as complete as you can.  This form needs to be completed by a parent or guardian. This will help us use our first session more productively, and may help clarify what your goals are for therapy.  If you are unsure about any of the questions, please feel free to discuss when you come into the office.  

Joint Notice of Privacy Practices and acknowledgment of Privacy Practice Receipt--  You don't need to bring the entire form in with you, just the last page where you have signed and acknowledged that you have read and understand Notice of Privacy Practices; you may wish to keep it for your personal file.  As of April 14, 2003 we are required by federal law to notify you of our privacy practices.  (These are the same type of forms that every medical professional must provide.  We have tried to make ours very clear and understandable.  Please be sure to ask me if you have any questions about this form.) 

© 2018 by inSession

  • White Facebook Icon
  • White Instagram Icon

Dynelle Helgeson RN, MA, LMFT  

ph: 612-568-8038

f:  612-314-8501 

e: dhelgeson14@gmail.com

3209  west 76th street

suite 202a

edina, mn 55435