Forms

Therapy services may be covered in full or partially based on your health plan

Please check your healthcare coverage before your initial session. Also, you may want to ask your provider the following questions:

Do I have outpatient mental health benefits?
Are there limits to the mental health therapy I am able to receive, and if so what are they?
Do I have to choose a therapist from a specific provider list, and if so is your therapist on it?
Do I have a deductible and if so, has it been met?
Do I have a copay and if so, how much is it per session?
How many sessions per calendar year does my plan cover?

Payment Methods

Cash, checks, and credit cards (Visa, MasterCard, American Express, Discover) are all acceptable methods of payment.

Payment is due when services are rendered.

Client Forms

Please find all the forms you will need for your initial consultation below. For your convenience, you can fill all of the forms out online and e-mail them back to your preferred provider, or, print out these forms to fill out to bring with you to your initial consultation.

To complete the online forms, please save the forms to your computer and complete using Adobe Acrobat. For more information and help, please visit:

How to Fill out and Sign a PDF document

Download Adobe Acrobat

Client Information Form

Welcome! As part of beginning the therapy process, please take a few minutes to fill out this form. This information will help me better understand your situation, and will help us both find solutions to the situations that are creating difficulties. Please note that this information is confidential.

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Informed Consent and Therapy Agreement

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask me any questions that you may have regarding its content before signing it.

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Authorization for Release Exchange of Information Form

This form provides your therapist at The Institute for Relational Change with written permission to communicate with other individuals regarding your treatment (i.e. previous therapist, current health care provider, etc.).

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Authorization of Treatment with Minors

The parent or legal guardian of each child who attends therapy sessions must complete this section. Some custody agreements require the signatures of both parents for treatment. Because of this, it is generally my policy to require the signature of both parents in any divorce/separation situation.

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Group Therapy Agreement Form

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask me any questions that you may have regarding its content before signing it.

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Policy for Electronic Communications Form

In order to maintain clarity regarding our use of electronic modes of communication (i.e. text, email, video conferencing, etc.) during your treatment, I have prepared the following policy. This policy has been prepared to assure the security and confidentiality of your treatment.

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Intern Informed Consent and Therapy Agreement

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask me any questions that you may have regarding its content before signing it.

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Our Vision

We envision a future in which systems-based family therapy plays a central role in improving mental health outcomes, strengthening relationships, and expanding equity across communities. As a leader in clinical training and a provider of accessible, relationally focused care, the Institute for Relational Change aims to contribute to a world where every person has the opportunity to experience healthy, supportive, and life-giving relationships.

The Institute is dedicated to training the next generation of systemic, culturally responsive clinicians.

SUPPORT

Support individuals, couples, and families attend therapy

Expand

Expand community-based programs that reach underserved neighborhoods

Provide

Provide scholarships for emerging clinicians

Develop

Develop training programs grounded in equity, inclusion, and social justice

The Institute for Relational Change is a 501(c)(3) nonprofit organization dedicated to providing therapy to underserved communities, and training the next generation of systemic, culturally responsive clinicians.