Intake Forms

Please print and fill out these forms prior to your initial visit.

Jeri Client Intake Form

Authorization for Release of Information


Current Procedure Terminology Code

Limits of Confidentiality

Notice Of Privacy Practices Form

Privacy Policy

"People are often unreasonable and self-centered. Forgive them anyway. If you are kind, people may accuse you of ulterior motives. Be kind anyway. If you are honest, people may cheat you. Be honest anyway. If you find happiness, people may be jealous. Be happy anyway. The good you do today may be forgotten tomorrow. Do good anyway. Give the world the best you have and it may never be enough. Give your best anyway. For you see, in the end, it is between you and God. It was never between you and them anyway." ~ Mother Teresa

Please read, print and fill out the "This is YOUR Life form and bring with Intake Forms.

This Is Your Life