Forms

Please print these single-sided and do not staple.

ADULT INTAKE FORM

All persons 18 and over must complete this form and bring it with you to the first appointment.

ANXIETY INVENTORY

Complete this form if anxiety is a major reason for requesting help.

CHILD/ADOLESCENT INTAKE FORM

For all clients under 18.

COUPLES FORM

Couples should complete an Adult Form for each person, plus this Couples Form discussed and filled out collaboratively.

IBS LOG

Download this form to track IBS symptoms.

OBTAIN INFORMATION FORM - CHILD & ADULT

Use this form to allow Mr. Glaser to obtain Personal Health Information from another professional.

RELEASE OF INFORMATION - ADULT 

Use this form for Mr. Glaser to release information about you to another professional, or for your own use.

RELEASE OF INFORMATION - CHILD

Use this form for Mr. Glaser to release information about your child to another professional.

 


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