Lori Gaylor MS, LPC
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  • Home
  • About
  • Contact/FAQ
  • Coaching
  • TELEHEALTH
  • New Patients
    • Forms
    • Rates
  • Location
  • Pay Online
  • Resources
  • COVID-19 Notice

Below are the forms needed for your first appointment:

If you are being seen through our TELEHEALTH system please fill out the forms and attach them in an email to us through our encrypted email option on the Contact/FAQ page. 

If you are coming into our OFFICE we ask that you please print and fill out the applicable forms and bring them to your first visit. 

The following six forms are needed from every patient: 
Patient information
Consent to treatment
Hipaa Privacy policy
Email/Text Consent
Confidentiality in therapy
Credit Card Authorization Form
The Teletherapy Informed Consent is only needed by those scheduling teletherapy sessions. Please complete this form if you think at any time now or in the future you would like to have a teletherapy session. 
Telehealth Informed Consent
The Insurance Agreement form is only needed from patients that will be using their insurance for payment.
insurance agreement

Required for Children/Teens:                                              Required for Adults:
child characteristics checklist
adult concerns checklist
amen child-teen checklist
amen adult symptom checklist
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