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Essential Forms

Please read carefully and bring all required documents to your first session. This is critical for our office to best serve you. Thank you!

Bring the following completed form to the first session or fax the day before to Psyche Associates at 303-617-3668. If you are using insurance or EAP, bring a copy of the front and back of your insurance card and check below for any additional forms required by your specific insurance company.

New Client Intake Form

Your signature on the above Intake Form indicates you have read and agree with my office policies including my cancellation policy. Here is a copy for you to read before our first session:

Office Policies & General Information Agreement for Psychotherapy Services

HIPAA Notice of Privacy Practices


Additional Insurance and EAP Forms — If your insurance company's form is listed below, complete and bring this with you to your first session along with the Intake Form and copy of insurance card.

United Behavioral Health Wellness Assessment Form

Anthem Blue Cross EAP Patient Signature Form

United Behavioral Health EAP Statement of Understanding Form


If you would like us to be able to communicate with your PCP or other health care professional about you, also bring this form to your first session:

Authorization Consenting to Release of Information

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Karen Rose, MFT
2140 Shattuck Avenue, Suite 503, Berkeley, CA 94704, or
870 Market Street, Suite 1065, San Francisco, CA 94102
Tel: (510) 486-1188
E-mail: rosekm@earthlink.net

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