Welcome to Rogue River Counseling

We look forward to meeting with you and exploring how we may begin a therapeutic relationship. We realize that this first meeting can come
with a tremendous amount of anxiety and/or caution. Being presented with a large packet of information may add to your feelings of discomfort or concern. With this in mind here are the forms to be filled out prior to your first appointment.

Policies and Procedures

This is a form that provides you the basic’s on what you can expect regarding the therapeutic relationship. Please read it over and submit it online.

Notice of Privacy Form

This is the notice of privacy that all healthcare professionals are required to provide their clients, informing you of your rights in regard to the privacy of your information. Please read, accept/sign and submit this form. If couple or family counseling, please have all parties over 18 read, accept/sign and submit this form.

General Intake Form

This form provides us with some general background information about you. Some of the questions are merely informational, and some are more personal. Please fill out what you are comfortable filling out, and we can discuss any questions you are hesitant to answer.

Request to Submit to Insurance Form

While Rogue River Counseling does not accept or work in conjunction with insurance carriers, one of the services we provide is to submit your Insurance claims electronically once a month. Many insurance carriers may reimburse you for part of your out-of-network expenses. If you would like us to submit your claims electronically please fill out and submit this form. When you arrive to your first appointment, provide us with a copy of your insurance card and driver’s license.

Credit Card Authorization Form

This form stays in our locked file cabinet and provides us the ability to charge your card after our sessions, when a minor is the client and the guardians are responsible for payment, or when a session is missed or cancelled without 48 hours of notice.

Telehealth Services Consent Form

This form discusses telehealth services four your understanding and knowledge of what to expect. Please read, sign/accept and submit it before engaging in Telehealth Services.

Please do not hesitate to discuss any question or concerns with me either prior to or at your first appointment. If you are unable to fill out this paperwork for any reason, please don’t be concerned. We can certainly walk through it together.

Fill out & submit these forms online.

Print the following form and bring it with you to your first appointment.


Sex Addiction


Betrayal & Trauma


Partners of Sex Addicts


The Relationship

We can help you navigate the rapids. For more information, please reach out to us.