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My office forms are available for download
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» Select the appropriate forms below by clicking on the link(s) below.
» Print the forms single-sided.
» Fill them out and bring them to the first visit.
» E-mail or call me if you have a problem downloading the forms.
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Adult Intake Form.pdf
(808K)All clients 18 and over need to complete a copy of this form. -
Anxiety Inventory
(53K)Complete this form if anxiety is a major reason for requesting help. -
Child/Adolescent Intake Form
(827K)For all clients under 18. -
Couples Form
(88K)Couples should complete an Adult Form for each person, plus this Couples Form discussed and filled out collaboratively. -
IBS Log
(39K)Download this form to track IBS symptoms. -
Obtain Information Form–Child and Adult
(80K)Use this form for Mr. Glaser to obtain information about you, or your child, from another professional. -
Release of Information–Adult
(58K)Use this form for Mr. Glaser to release information about you to another professional. -
Release of Information–Child
(21K)Use this form for Mr. Glaser to release information about your child to another professional.