Intake Forms

If you’re a new patient, please print out and complete the following form and bring it to your first therapy session.

Please note that we are not a Medicare or Medicaid provider and you will therefore not receive reimbursement from Medicare or Medicaid for our services. If reimbursement is very important for you, the best option may be to seek out a Medicare or Medicaid provider.

Dr. Thorsheim Forms

Patient Assessment Intake Form

Download Form

Disclose Information Form

Download Form

If you would like Dr. Thorsheim to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.),
please complete the Disclose Information Form to authorize release of psychotherapy information.

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