Helpful Forms

If you're a first-time client, please review and complete the following forms, fax them to me before the first session (especially insurance verification form) or bring them to your first session.

• Client Personal History / Intake Form
• Couple's Counseling Information Form -One for each person ***Note: If you are coming for couples counseling please also fill out the adult intake form for both people***
• Personal History - Children and Adolescents (<18)
• Limits of Confidentiality/Cancellation and Payment Policy Form
• Your Family Matters Insurance Verification form

If you would like me to coordinate care with another provider (for example, your medical doctor, psychiatrist, endocrinologist, etc.), complete this form:

• Consent to Release Information Form

Note: Applicable forms below must be downloaded, printed and filled out manually. Then scan and email to [email protected]. You may also fax them to (763-427-5688). If necessary they also may be brought to the first session.

Consent to Release Only if requested by Dr. Dousi
Personal Histo ry - Children and Adolescents (18 )
Adult Client over 18 Personal History Intake Form Note: 1 Form for EACH Adult in Couples or Marriage Therapy
Couple's Counseling Information form - One form for each person-
Limits to Confidentiality, Cancelation and Payment Policy Note: 1 signed for each participant YFM Insurance Verification Form Note: Email to [email protected] ( YFM Insurance Verification Form Note: Email to [email protected] ( prefered )  or Fax to 763-427-5688 BEFORE the 1st session if possible )  or Fax to 763-427-5688 BEFORE the 1st session if possible

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