Debra Gibbons – Licensed Marriage and Family Therapist and Clinical Member of AAMF

Teen, Individual, and Family Counselor

Intake Documents

Intake Documents to be filled out and brought to the First Session:

Please download and print the appropriate intake documents below. Adult clients 18 and over will need to print and fill out the Adult Intake as well as Notice of Privacy Practices, and Disclosure Statement. If you intend to use your insurance you need to print and sign the Release of Information form. The Child Intake form is for children under 18 years. If you are a parent of a child under 18 years please fill out the Child Intake form as well as Notice of Privacy Practices, the Disclosure Statement, and the Credit Card Form. If you intend to use your insurance you must print and fill out the Release of Information form. Forms must be signed and filled out before the first session.

Please note the portion of the intake forms which pertain to insurance needs to be filled out prior to our first session. Please check with your insurance company to make sure services are covered and how much deductible has been met and what your co-pays are. This will help you to understand what your financial responsibility is before you begin therapy.

Adult Intake

Child Intake

Credit Card Form

Disclosure Statement

Notice of Privacy Practices

Release of Information Insurance