Client Information Form

My goal is to help you professionally and in confidence. Please complete the electronic form below.

There is no need to print this, as these forms are automatically sent directly to me upon submit. Your information is strictly confidential and professionally considered. Thank You!

Your Information This image has an empty alt attribute; its file name is jkayhouse.png

    Marital Status

    Emergency Contact (Required)

    Please select your insurance provider

    Previous Couneling or psychological care?

    Spouse's Information

    Children's Information

    *Required fields. I value your privacy and do not sell or share your information.

    "I understand that I am responsible for payment at the time services are rendered (unless insurance payments are authorized payable directly to provider for insurance services). I agree that any assistance for reimbursement from insurance does not absolve my full responsibility for payment.

    Signature of Person Responsible for Payment