Client Information

Required background information on the identified client, the identified client (one family member must be chosen) will be billed if insurance is used and will receive a mental health diagnosis, and the form must be signed and dated by the identified client or by a parent or guardian, in the case of a minor.   Download Client Information Form.

Financial Agreement

Required. Please read, sign, and date by the identified client or by a parent or guardian, in the case of a minor. Download Financial Agreement Form,

Late Policy

Required. Please read, sign, and date by the identified client or by a parent or guardian, in the case of a minor. Download Late Policy Form.

Client Disclosure

This release form allows communication with other persons or agencies such as a Primary Care Physician.  If insurance is used, a disclosure must be filled out for the insurance company. The identified client name goes on the first blank line. The second blank line is the person, insurance company, or agency to receive the released information, Finally, the form must be signed and dated by the identified client or by parent or guardian in the case of a minor. Download Client Disclosure Form.

Informed Consent

Required. Please read, sign, and date by the identified client or by a parent or guardian, in the case of a minor. Download Informed Consent Form. 

Curriculum Vitae

Here is more in-depth information about my background. Download Dr. Thorbecke’s Vitae.

Client Background Information

Not required. This form will allow you to give me more background information. Download Client Background Form.