928-254-0113

CLIENT HISTORY AND INTAKE FORMS

For your convenience, intake forms are available here that we will be discussing in our first session.  Please complete these documents and bring them to your initial scheduled appointment time.  We can discuss any concerns that you might have before you sign the Consent for treatment form.  If you can scan and email the completed documents before your session, it is not necessary yet saves time in the initial session.  Please email them to junipercampbellcounselor@gmail.com.  If you cannot print out the forms, please notify Juniper and arrive 20 minutes before your session to complete your intake paperwork.  

NEW PSYCHOTHERAPY CLIENT FORMS ​ (please read and sign all four forms listed)

Intake Form​​

 Symptom Checklist

Consent for Treatment

 Additional Information About My Practice

​HIPAA

NEW PSYCHOTHERAPY CLIENT FORMS - COUPLES (please read and sign all four forms listed)

Couples Intake (to be filled out separately by each partner)

Couples Consent for Treatment (there is a signature line for both of you to sign)

Additional Information About My Practice

HIPAA (there is a signature line for both of you to sign)

​​SUPPLEMENTAL FORMS - DO NOT FILL IN SUPPLEMENTAL FORMS UNLESS REQUESTED

TeleCounseling Consent

Consent for Release of Information

Consent to attend as a visitor

Consent for a visitor at a session