Susan E. Folwell, LCSW, LICSW, BCDV -

Primary Forms
To facilitate the best use of  the initial intake and evaluation session please download and complete the following forms prior to your appointment.

Policies and Procedures: This document must be brought to the first session.  It contains important information about Susan's professional services and business practices. 
Financial Agreement: This document contains important information about fees and agreements between client and therapist.  It must be signed prior to the first session.
 Confidentiality Agreement:  This document is needed for the first session and contains important information about confidentiality and any mandated limits of confidentiality that may arise in psychotherapy.
Medicare Opt-Out:This document contains information regarding therapist's non-participation in Medicare and must be signed and brought to the first session.
New Client History and Contact Information:This document is needed for the first session in order to provide basic background information.
HIPAA: please sign acknowledgment of receipt of notice of HIPAA.

Additional Forms if Needed
Authorization to Release and Share Information: This form must be completed and signed if you would like for Susan to speak to another person regarding your treatment.  This may include a psychiatrist, another therapist, an attorney, a close family member, a medical professional, etc.  With a firm commitment to confidentiality, Susan will not acknowledge anything about your treatment, including whether or not you are even in treatment. 

Consent to Treat a Minor:  This form must be filled out  by any parent or legal guardian who has legal custodial rights for a minor client before treatment can begin. Upon occasion, especially in cases where litigation is a concern, Susan reserves the right to request a copy of custodial documentation, and other pertinent documents, to be included in the client file.