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Client Forms
If you have decided to seek the services of Dana Schneider please review, complete and bring
to the first meeting the following forms:
- Client Intake
- Consent to Treat
- Release of Information
Some of the questions may not pertain to you or your situation. Feel free to simple skip
over
those questions or discuss them in our first meeting. If you have any questions please contact
Dana.
Client Intake
This is a detailed questionnaire that helps Dana with historical and developmental
information that can be very useful in the first meeting. This form enables Dana along with the
client to begin identifying goals for counseling.
intake-form.pdf
Consent to Treat
This is a brief form clarifying Dana's office policies and practices including the limits to
confidentiality.
client-consent.pdf
Release of Information
This is a form that allows Dana to discuss your history, school records, medical and
psychological information with collateral professional contacts.
info-release.pdf
Detox Negative Intimacy
This is a chart prepared by Isolina Ricci, Ph.D and provided with her permission. I often
refer to this form when working as a co parenting counselor.
detox-negative-intimacy.pdf
Four Parenting Patterns
This is a chart prepared by Isolina Ricci, Ph.D and provided with her permission that
identifies the 4 parenting patterns commonly used after divorce.
parenting-patterns.pdf
Bibliography
This is a list of publications, articles and books that may be helpful to you.
Bibliography.pdf
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