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 Show Forms button below to open the documents. Place your curser on the lines you are filling out, type your information, then print.
**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 or Chrome Notebook – 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.
No Surprises Act
CHILD (Under 13 years of age)
*Please review and sign required forms before meeting with Dr. Kessler
Standard Forms
*Intake
Treatment agreement document for review
*Signature page acknowledging Treatment Agreement – Child
Privacy Policy for review
*Signature page acknowledging Privacy Policy
Consent Authorization for use of Unencrypted E-mail
Additional forms
TEEN (13 years of age and over)
*Please review and sign required forms before meeting with Dr. Kessler
Standard Forms
*Intake
Treatment agreement for review
*Signature page acknowledging Treatment Agreement -TEEN
Privacy Policy for review
*Signature page acknowledging privacy policy
*Authorization for use of Unencrypted E-mail
Additional forms
DIVORCED/SEPARATED PARENTS of Child
*Please review and sign required forms before meeting with Dr. Kessler
Standard Forms
*Intake
Treatment agreement document for review.
*Signature page acknowledging Treatment Agreement – DIVORCED/SEPARATED
Parent Authorization for Minors Mental Health Treatment with Separated or Divorced Parents
*Signature page acknowledgment to authorize minor’s mental health treatment with separated or divorced parents
Privacy Policy for review
*Signature page acknowledging Privacy Policy
*Authorization for use of unencrypted email
Additional forms
*Authorization to Exchange information
Collateral Agreement
ADULTS
*Please review and sign required forms before meeting with Dr. Kessler
Standard Forms
*Intake
Treatment Agreement for review
*Signature page acknowledging Treatment Agreement -ADULT
Privacy Policy for review
*Signature page acknowledging Privacy Policy
*Authorization for Use of Unencrypted E-mail
Additional forms
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