Bernard J. Sullivan, Ph.D.

Intake Forms for First Counseling Session:

You may also fill this out when you come to the first session.

First Form – Consent Form

Please, print this form (including a copy for yourself), read, answer yes or no in three places, sign, and bring to the session.

Download the Consent Form

Second Form – Intake Information Form

Please, print this form, fill in, sign, and bring to the session. You may skip the insurance information if you have your insurance card for us to copy. Please print the insured’s name and birth date in this section if that is someone other than you.

Download the Intake Information Form

Third Form – Kansas Notice Form

If you wish, read and print for yourself. This form is not necessary to bring to your session.

Download the Kansas Notice Form

© 2024 by Bernard J. Sullivan, Ph.D. All rights reserved.