Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

1. OPA Telepsych Consent Form - opa-telepsychology-informed-consent-form.pdf

2. TLC Consent Packet - tlc-consent-packet.pdf


If you are a Neuropsychology patient, please complete the following questionnaire in addition to the form and packet above.

1. Neuropsychology Questionnaire - neuropsychology-questionnaire.pdf


If you would like Dr. Shaw to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information.

1. Authorization for Release of Protected Health Information - transitional-life-counseling-roi.pdf


If you are a provider looking to refer someone for care, please complete this packet.

1. TLC Referral Packet - tlc-referral-packet.pdf


Confidentiality & Privacy Policy 

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission. 

Exceptions include:

  • Suspected child abuse or dependant adult or elder abuse, for which we are required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, we must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, we will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, we will take further measures without their permission that are provided to us by law in order to ensure their safety.

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