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Client Forms

The information and forms posted here are provided to expedite the initial session for those who wish to complete these necessary paperwork prior to arriving for the first session. You may choose to print the appropriate forms and bring them completed to your first session, or you may wait and complete forms that we provide upon your arrival. The necessary forms will be available, upon request, in the waiting area when you arrive for your first session. The links below are for PDF files of each form. To download Adobe Acrobat Reader for free, click here.

Please be aware that all therapists at the ICFE are independent practitioners, which means each has some individualized paperwork for new clients, such as a consent form. Below are links to general forms to be completed by all new ICFE clients, as well as links to consent forms for each therapist. The link will either take you to a pdf file of the form, or to the therapist's professional website page where you can directly download the correct forms. If you are unsure which therapist you are seeing, please call (210) 496-0100 or complete the Contact Us message and someone will get that information to you asap. If in doubt, you can simply complete the general forms below prior to your session and then complete your therapist's consent forms at your first appointment. 

General ICFE Forms for Use by All ICFE Clients-

If you're a new adult client, please complete the Adult Client Information Form and bring it to your first therapy session. Each adult attending therapy should complete a separate form, as much of the information will be different for each individual. This form is also needed for parents who are bringing a child for therapy. In almost all cases, parents will be expected to participate in a least some of the therapy sessions with their children and are, therefore, considered psychotherapy clients along with their children.

If you are bringing a child or adolescent for therapy, please also complete the Child Client Information Form in addition to the forms needed for adults who will be attending with the child(ren). At the ICFE, Children are treated within their family context- this means that both the child and his or her parent(s) are considered psychotherapy clients. Also, please be aware that you are required to provide a copy of any court order or decree that impacts child custody and guardianship, including rights to consent for psychological and mental health treatment. 

In order to provide you with the best care possible, your therapist will may request to coordinate your care with other relevant professionals (for example, your psychiatrist, primary care physician, child's school, etc.). A signed Release of Information will be required to allow your therapist to talk with anyone else regarding you or your family members. Your therapist will talk with you to determine who may need to be included in your care, what may be released and to whom. Your confidentiality is vitally important within our work together. Please bring contact information with you for any other professionals with whom you think it might be important for your therapist to communicate.

A Pre-Authorized Billing Agreement is available for clients' convenience and therapist protection. Payment arrangements are made through your therapist; however, ICFE therapists may require a credit card be left on file while clients are actively involved in therapy in order to cover outstanding balances, including charges for late cancellations or no shows and returned checks.

All therapists at the ICFE have adopted specific privacy practices to manage clients Private Health Information in compliance with HIPAA and other state and federal laws, as well as professional ethics codes. These practices are detailed in our Notice of Privacy Practices. It is not necessary to bring a copy of this form to your initial appointment. The consent form you complete with your therapist includes an acknowledgement of receipt or access to this document. 
 
Consent Forms for ICFE Therapists

All adult clients must read and sign/initial the Informed Consent document prepared by their therapist. Please select the form under the name of your therapist, or follow the link to his/her professional website.

Daisy Ceja, MS, LMFT-Associate                                 Adult Consent Form            Minor Consent Form

Amanda Collins, MA, LMFT                              Click here to be directed to Ms. Collin's website for forms.

Emily Daniels, MA, LMFT-Associate                            Adult Consent Form             Minor Consent Form

Becky Davenport, Ph.D., LMFT-S               Click here to be directed to Dr. Davenport's website for forms.

Joseph Estess, MA, LMFT                              Click here to be directed to Mr. Estess's website for forms. 

Kyle Jankowski, MA, LMFT                                            Adult Consent Form                Minor Consent Form

Melissa McVicker, Ph.D., LMFT                                    Adult Consent Form               Minor Consent Form

Kirsten Northrup, MA, LPC, LCDC, LMFT-Associate    Adult Consent Form

Jason Northrup, Ph.D., LMFT-S, LPC-S                       Adult Consent Form               Minor Consent Form

Jessica Potter, MA, LMFT-Associate                           Adult Consent Form               Minor Consent Form

Jennifer Soos, MA, LMFT                                            Adult Consent Form               Minor Consent Form

Carolyn Tubbs, Ph.D., LMFT-S                                    Adult Consent Form              Minor Consent Form

Ashley Wilkens, MA, LMFT, LPC                                 Adult Consent Form

Nicholas Wilkens, Ph.D., LMFT-S, LPC-S         Click here to be directed to Dr. Wilken's website for forms.


 

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