Intake Paperwork.

Please print and complete the following forms prior to your first appointment.  If you have questions regarding the paperwork please contact Andrea.

 

Click Print Icon Below to Print

Intake

Packet

Release of Information

Credit Card

Authorization

Includes demographic and insurance information along with information regarding confidentiality and consent for treatment.

Please complete for any person that need to have regular updates on treatment or you would like me to be able to communicate with regarding treatment.  This may include, previous mental health providers, primary care physician, or a psychiatrist if you have one.

Credit Card form that authorizes one time use or recurring use for co-pays, deductibles, etc.

Andrea Gustafson

4725 Merle Hay Rd.

Suite 205

Des Moines, IA 50322

 

(515) 777-1209

 

andrea

@jmgtherapy.com

© 2014 by JMG Therapy & Counseling Services, LLC