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Shirley Johnson, LCSW
541-890-3066
14 Cottage Street
Medford, Oregon 97504
info@shirleythetherapist.com
FORMS

Please read the "Notice of Privacy Practices" below, and then print out and complete the "Client Information Form" to bring in with you.  I need one "Client Information Form" and one "Client Intake Questionnaire" for each person being seen.    If you are coming in for individual therapy, please complete the "Therapy Contract" to bring with you.  If you are coming in for couples therapy, please complete one copy of the "Therapy Contract for Couples" for both of you to sign and bring in with you.     (note: you may need to have Adobe Acrobat Reader installed on your computer to access the forms)

 


If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

 

 

 

 

 

 

 

 

 

Note: To download Adobe Acrobat Reader for free, click here.