Professional Disclosure Statement

Please print, read, and sign for your first session with Priscilla Klockner

Child In-Take Form

This form is to be used for new clients under the age of 12.

Release of Health Information

Use this form to authorize release to, or from, Priscilla Klockner to a third party.

Good Faith Estimate Information

As of January 1, 2022 a new federal law called the No Surprise Act goes into effect. Under this law, all health care providers, including mental health therapists, need to give patients/clients who do not have insurance or choose not to use their insurance an estimate of the bill for medical items and services.