(forms may not be up to
Minimum = 6;
Portland Area CoDA Mtgs
-Phone: for 2012 dates
-Simona Borza, PMHNP
-John Crippen, LMFT
-Bob Davidson, LMFT
-Heidi Hart, PMHNP
-Brooke Miller, LCSW
-Audrey Spencer, ASU
It would be helpful to have all forms filled out before therapy begins.
The forms are created in Acrobat Reader format. If you do not have that
program, you may download that program free. If you have problems
downloading any of the files in Acrobat, you are probably using an older
version, like 4.0. Most the forms are in version 5. Click on the
icon to get the latest version of Acrobat Reader.
You can fill out the forms on your
computer, then print them out.
However, you do not have to fill the forms out on the computer. You can
send the forms directly to your printer. The
Instruction Checklist would be helpful for you to print out and use as a
this out. It will help explain which forms you need.
must sign and date. Print second copy for yourself. Click on
contract under desired therapist because contracts are different. If
you have questions about the contract, you may raise them with the therapist
at your first session (or for that matter, any time).
||A must for all new
clients to fill out. One form per family, designating the identified
patient (IP) for billing purposes. If you phone, this information is
gathered by the office staff or therapist.
This may take up to 1 minute to download,
per page (4 pages). This history is very helpful and will save the
therapist a lot of time, reserving the therapy session for discussion and
conversation about the presenting problem and your needs. If
marital, both need to fill out this form.
Each person fill out. This information is helpful to make sure
that we are treating the whole person.
Verification Form is for your assistance to help you find out your
insurance coverage. There are suggested questions that you could ask
and helpful things that you need to know when dealing with your HMO.
Managed Care Notice
Insurance Clients: Read, Information about insurance billing and
||Each counselor is
required to provide this statement about themselves. please read and
printout for your information. Print out the one on your
||This is our brochure
that you may print out. Share with a friend. This tells more
about us. Our graduate student has a separate flier.
What You Should Know
"What You Should Know About Marital and Family Therapy" Handout
Release of Confidentiality
For sharing records and/or treatment goals and outcomes between counselors,
lawyers, pastors, teachers, non-custodial parent, etc.
Four pages, parent fills out on child's behavior, desired changes,
problem areas, etc. Form can be typed, then printed out or printed out
and then filled in. This form is if the child is the identified
Couple: 3 Questions
These three questions are most helpful when you come in as a couple.
Each spouse fills one out. This form will help you get your
thoughts organized and clarify what your needs are in the relationship.
These questions might be helpful to clarify your thinking as a couple.
If you desire, fill out and answer the questions that you think are
significant and important. Fax ahead of session or bring to your next
||When couple come in for
therapy, they find this agreement helpful. It is an agreement between
the couple that they want their therapy to remain confidential under all
circumstances. Print out the one with your counselor.
DBT Diary Card
For those attending the DBT Class.