Clinical Forms

For your convenience, you will find on this page several of the clinical forms that I use most often in my private practice. In all cases, you can print these forms directly to your printer so that you can fill them out at home. In some cases, you may submit them directly online.

Intake Forms

1) Consent forms. These include an "Informed Consent and Authorization for Services," form which is a summary of important information about Cobb Counselling & Consulting. It answers many common questions about confidentiality, fees, and frequency of visits. There is also a "Consent to be Contacted" form which allows you to define how you would like to be contacted by Cobb Counselling & Consulting in the future.

2) An intake questionnaire. The purpose of this questionnaire is to aid assessment and treatment planning by giving me a broad overview of your background and current situation at a glance. All information you provide in this form will be kept as part of your confidential file.

It should take about 10 minutes to complete these forms. So that we can spend your session time focusing on your concerns and not paperwork, I prefer to have you fill them out ahead of time, before the start of the first session. Clicking on a link below will open a PDF version of these forms in a separate window. Then you can print the forms directly to your printer, complete them at home, and bring them with you to the first appointment.

You can access the regular intake forms at the following link.

Regular Intake Forms

However, if you are coming specifically for a Marriage Checkup please use the following link instead (the informed consent forms are different).

Marriage Checkup Intake Forms

Finally, if you have children under 18 years of age and you are seeking therapy for them or with them please use the following link (there are additional forms to complete for child or family therapy).

Child & Family Intake Forms

Authorization for the Release of Confidential Information

There may be times when you need me to speak to someone right away, but are unable to make a separate trip to my office to provide me with your written consent. In this case, you can download the necessary form here in a PDF file, print it, complete it, sign it and fax it back to my confidential fax number and/or send the hardcopy to me by mail.

Note: this form is not part of the regular intake package. Completing this form is only for those occasions when you may want me to communicate with a third party.

Release of Confidential Information Form

Client Satisfaction Surveys

There are two ways to use these surveys:

• OPTION A: periodically complete one or more client satisfaction survey's every 3 to 4 sessions and a closing survey at the end of counselling.
• OPTION B: complete the closing survey only at the end of counselling.

1. Client Satisfaction Survey—Periodic

This survey is meant to be filled out every 3-4 sessions on a periodic basis. Your responses give your therapist immediate feedback about whether counselling is "on the right track" or whether adjustments are needed to make it more helpful to you.

Click here to complete a Periodic Survey online
Click here to open a hardcopy of the Periodic Survey





2. Client Satisfaction Survey—Closing

This survey is to complete at the end of counselling services when you have no further scheduled visits. It is intended to provide information about your overall experience with Cobb Counselling & Consulting and the progress you made over time.

Click here to complete the Closing Survey online
Click here to open a hardcopy of the Closing Survey