Plant

Forms

Forms can be filled out electronically through our patient portal. You may also fax completed forms to (844) 479-2683. For individuals who are not a current client of Head and Heart Therapy, it's important to set up a free consultation in order to become a client. 

Grievance Policy

Grievance Form

Informed Consent for Telehealth Services

Informed Consent for In-Person Services during COVID-19

Sliding Scale Fee Schedule 

Sliding Scale Application

Personal Disclosure Statement

Sarah Dobey, LPC, MAC, ACS

Marissa Cano, LPC Associate

Sabrina Arnold, LPC Associate

Release of Information

Sarah Dobey, LPC, MAC, ACS

Marissa Cano, LPC Associate

Sabrina Arnold, Student Therapist

Maggie Nidick, Student Therapist

Other Forms

Feedback Form

COVID-19 Questionnaire

Financial Agreement Form

Practice Policies

Notice of Privacy Practices