Specializing in Children with Emotional and Developmental Challenges

Phone 818-248-6414

Forms

To help you get started, Dr. Kessler’s intake forms are available here allowing you to print and fill them out prior to your visit. Simply click the links below to open the forms.

To fill the forms out by hand, save them to your computer and print.

Please fill out the forms in * below before your appointment. Click on the links below to open the document.  Place your curser on the lines you are filling out, type your information, then print.

*Intake Form PDF
*Authorization Form PDF
Treatment Agreement Form
*Treatment Agreement Signature page PDF
Office Privacy Policy PDF
*Office Privacy Policy Signature PDF
Addendum to Psychologist-Child Agreement: Confidentiality with Minors and Parents PDF
Telehealth Written Consent Form PDF
Treatment Agreement When Treating Children of Divorce PDF
Outpatient Services Agreement for Collaterals

And the day came when the risk it took to remain tight in the bud was more painful than the risk it took to blossom Anais Nin

 

 

**Some browsers do not support opening documents in new windows/tabs or editing them within the browser. Below are instructions for popular browsers:

Firefox-open link and edit within browser-save final edit to your computer to print out.

Internet Explorer (some versions)-right click link and click “save target as” to your computer’s files to print out later.

Google Chrome-click link to open then right click on the document, click “save as” to your computer’s files to print out later.

Some browsers may automatically download the form to your computer when the link is clicked, depending upon your settings.**
SaveSave