Please print these single-sided and do not staple.
Use this form if you will be seeing me using video sessions. It includes the Telehealth Consent Form. See instructions on page 1 to return the form to Mr. Glaser.
Please fill out and submit this form to firstname.lastname@example.org to authorize telephone and/or video sessions with Mr. Glaser.
All persons 18 and over must complete this form and bring it with you to the first appointment.
Complete this form if anxiety is a major reason for requesting help.
For all clients under 18.
Couples should complete an Adult Form for each person, plus this Couples Form discussed and filled out collaboratively.
Download this form to track IBS symptoms.
Use this form to allow Mr. Glaser to obtain Personal Health Information from another professional.
Use this form for Mr. Glaser to release information about you to another professional, or for your own use.
Use this form for Mr. Glaser to release information about your child to another professional.