"One generation plants the tree, another gets the shade"

 

Joan Fenold, MFTGina Kramer, MFT

Therapy for Children, Adolescents and Adults

Contact Gina
707.334.4704
1434 Third Street, Suite #3A
Napa, California 94559

INTAKE FORMS:
Please complete and print the intake forms listed below and bring them with you to your initial session.  This will allow us to complete the intake and assessment process more quickly.  We will review the forms at the first session and I will be happy to answer any questions.

Intake Paperwork:

CHILD & ADOLESCENT INTAKE ASSESSMENT FORM  
Please complete this form for any child under the age of 18. Feel free to leave sections blank or write in N/A if the question does not apply to you or you are uncomfortable answering.
Child & Adolescent intake assessment form PDF

ADULT SELF-ASSESSMENT INTAKE FORM
Please fill out before first session. Feel free to leave sections blank or write in N/A if the question does not apply to you or you are uncomfortable answering.
Adult Self-assessment form PDF

​INFORMED CONSENT/OFFICE POLICIES
A document describing the counseling process, fees, procedures etc... Requires client signature. Mandatory form.
Informed Consent form PDF

HIPAA / Receipt of HIPPA Privacy Policy
Informational Only- Please sign receipt listed on last page of the Informed Consent/Office Policies.
HIPPA Form PDF

ELECTRONIC COMMUNICATION DISCLOSURE FORM
Describes the limits to confidentiality presented by electronic communication- or e-mail and establishes practice's policies. Requires client signature, or decline.
ECD form PDF

AUTHORIZATION TO PROVIDE TREATMENT TO MINOR
Please complete and sign this form for ANY child under the age of 18. If divorced, please have both parents sign if possible.
Authorization to provide treatment to a minor form PDF

Additional Documents Needed:

For divorced parents of minor clients, please bring a copy of the custody agreement to the intake session so that I may verify who may consent to treatment.

If you wish to have me provide you with a Super Bill for insurance billing purposes, please bring me a copy of the front & back of your insurance card.

If there are other people that I will need to be in contact with regarding your treatment, please print and complete:

AUTHORIZATION TO EXCHANGE INFORMATION​
Complete this form if communication with a school, doctor, or other outside organization/person is needed to help you. Please complete a separate form for each entity.
Authorization to exchange information form PDF