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spacerDr. Susan Rosenweig, Psy. D.

INTAKE FORMS:
The forms are PDF forms: you may type the information requested into the forms or you may print the forms and fill them out entirely by hand. Some parts require your signature, so even if you type most of the information, you will still need to print the forms to complete them. YOU CANNOT SAVE THE DATA IN THE FORM.

Please bring the completed forms with you to your first appointment. I will also have you complete two symptom checklists when you arrive for your first appointment.  Because of copyright laws, I cannot post them on my website.

The information you provide is kept in strictest confidence. The information is used to aid us in developing a plan to best meet your objectives in therapy. The information on the insurance information form assists us in billing your insurance company.

If you are unable to download and print these forms, be sure you have Adobe Reader installed on your computer.

I can mail the forms to you if you request it.  Please call the office voicemail to request that we send you a new client packet.  Please be sure to leave your complete address on the voicemail.

Download Complete Forms (14 page PDF)

 

 

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2476 NW Northrup Street
Suite 2B
Portland, OR 97210
Tel. 503-206-8337
Fax 503-206-8032

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