Intake Forms

There are several forms (linked below) you will need to complete before we begin our work together. These forms are also available through the Patient Portal (you will receive a link to sign up for this once an intake appointment is scheduled). Alternatively, completed forms can be emailed. You do not need to print the Notice of Privacy Policies unless you are interested in having a paper copy. You only need to complete the Authorization for the Release of Clinical Record if there is another individual or professional you would like Dr. Samson or Dr. Lewis to speak with in regards to your or your child’s care.

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• Adult Patient Information Sheet

• Child/Adolescent Patient Information Sheet

• Credit Card Permission 

• Health Information Consent

• Patient Agreement

• Permission to Release Information

• TeleHealth Agreement

• Use of Email Agreement Form

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Submit a Form: