Kim Shaffer, LCPC, Counseling Services

If you would like me to coordinate care with another provider such as your psychiatrist or primary care physician, complete this form to authorize release of psychotherapy information:

• Demographics
• Medication Record
• Patient Health Questionnaire (PHQ-9)
• Beck Anxiety Inventory
• Adverse Childhood Experence
• Telehealth Counseling Agreement
• AC-OK Screen
• Client Intake Form
• Client Confidential Communications
• Checking Coverage
• Notice of Privacy Practices