Daniel M Zimet, PhD, CMPC, LLC
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You will need to complete 2 forms and review 2 forms:
  • Please complete the Consent to Treatment form and complete the appropriate Intake Questionnaire below for either adult, child, athlete, or both partners for the couple form.
  •  The Outpatient Services Contract and HIPPA form is for your review only.
FORMS FOR COMPLETION:
Consent Form
File Size: 218 kb
File Type: pdf
Download File

Adult Intake Questionaire
File Size: 148 kb
File Type: pdf
Download File

Child Intake Questionaire
File Size: 248 kb
File Type: pdf
Download File

Couple Intake Questionaire
File Size: 204 kb
File Type: pdf
Download File

FORMS FOR REVIEW ONLY:
Outpatient Services Contract
File Size: 226 kb
File Type: pdf
Download File

HIPPA Form
File Size: 161 kb
File Type: pdf
Download File

Athlete Intake Questionaire
File Size: 200 kb
File Type: pdf
Download File

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