Forms & Documents
For your convenience, I’ve provided the following forms in downloadable, printable versions, to make getting started and accessing treatment easier. Please complete the forms and bring them to your first appointment.
For your first session. New child and adolescent clients need the intake paperwork, symptom checklist, and child history form. Adult patients do not need to complete a history form — adults can usually provide that information during the first session.
1 Intake Paperwork
The basic information and consent forms needed to begin treatment with Dr. Goldner. For a minor child (under 18), it is encouraged, where possible, that both parents or legal guardians sign these forms — regardless of marital status or divorce — although one parent may initiate treatment alone, without the consent of the other, in accordance with state law. Note: filling out these forms alone does not create a therapeutic contract or relationship. An intake session must be completed and Dr. Goldner must agree to treat the individual as an ongoing client before treatment begins. Only one parent must be present at the intake session to initiate treatment.
Download (PDF)3 Child History Form
A detailed questionnaire required for new child and adolescent clients. Adult clients may choose to complete it, but in my experience adults can usually provide this kind of detail during the first session. Bringing a completed history form to your first session will save time during intake.
Download (PDF)4 Release of Information Form
Any client information you give me — even the fact that you come to see me for treatment — is privileged and confidential. I require a completed Release of Information Form before I can discuss your or your child’s case with anyone, including teachers, administrators, physicians, and other helping professionals.
Download (PDF)5 Teletherapy Consent Form
Teletherapy is a service provided to Dr. Goldner’s established clients. To be established, you must complete an in-person intake session, unless special circumstances are involved.
Download (PDF)6 Notice of Privacy Practices
As a client, your privacy is protected by numerous laws, rules, and ethical regulations (HIPAA — the Health Insurance Portability and Accountability Act). The Notice of Privacy Practices is a detailed explanation of your privacy rights.
Download (PDF)Contact Dr. Goldner
Questions about any of these forms, or about getting started? Contact me directly — by email or phone.