New Patient Intake and Forms

Please click on the link below to begin the private web based registration process for Kirkland Psychotherapy Inc.  When complete you will be asked to check a box indicating you have read my Privacy Practices and Office Disclosure/Permission to Treat Forms. PLEASE PRINT, FILL OUT AND SIGN THESE FROMS AND BRING THEM WITH YOU TO YOUR APPOINTMENT.  Please do this at least one business day before you come to your appointment.

https://www.compulinkadvantageweb.com/prod/register/accountappts/index/5027  

Alternatively,  If you chose not to use the web based registration, using the contact form below, you can read, fill in, sign, scan and then attach the documents listed below  Including all forms in one PDF document is fine.  Your information will be sent to me in an encrypted form to insure your privacy.  I need all documents for all participants one business day before your first appointment.

 You may also send them to me in the mail at:

Kirkland Psychotherapy, Inc

11415 NE 128th St. Suite 100,

Kirkland, WA

Please bring your insurance card and photo ID to the first session as well as verify your coverage and out of pocket costs.

NEW PATIENT INTAKE. INFO FORM 1.5.16

NOTICE OF PRIVACY PRACTICES

INTAKE 4.1 PRACTICE DISCLOSURE STATEMENT AND PERMISSION TO PROVIDE CARE SM 3.21.16

For encrypted email contact form click below:

Contact Form