I specialize in evidence-based psychotherapy and psychological evaluation for school-age children and teens, and I offer after-school and weekend appointments at my office conveniently located near I-5 in the Tigard Triangle area of Portland on 72nd Avenue at 217.
Payment is accepted at the time of service in cash, check, or Zelle sent through your bank’s app to email@example.com. Zelle may not be a private way to pay.
Families are required to store a credit card on file, for those times when cash, check, or Zelle payment is inconvenient for you. FSA and HSA cards can also be stored on file. Cards stored on file and online payments (using the link below) can be accepted instead of cash, check, or Zelle, as a convenience to you with a $4 fee.
Please complete the Questionnaire and Agreements, and return them to me before your scheduled appointment, along with copies of past evaluations, relevant school information, report cards, standardized test scores, etc. The authorization form is an optional form you can use to allow me to release or obtain information from someone else.
This questionnaire covers historical information to assist me in a thorough evaluation or consultation. I see children of all ages with differing problems, so some questions may be irrelevant to your child. You may ignore questions that do not apply or add additional details on the last page.
Authorization to Use and Disclose Protected Health Information
With this form, you can authorize me to:
- provide specific protected health information to someone.
- receive specific protected health information from someone.
- provide and receive specific protected health information.
For example, you might decide to allow exchange of specific information with a physician, psychologist, or school.