Please note that the only form you are requested to print out, fill in, and bring with you to the first session is the Client Information Form. The Consent for Services and other forms will be reviewed with you at intake.



Client Information Form (PDF Format)

Consent for Services Form (PDF Format)

Notices of Privacy Practices (HIPAA) (PDF Format)

Mental Health Bill of Rights (PDF Format)

Authorization to Release Information Form (PDF Format)

Child Receiving Services Consent Form (PDF Format)

Teletherapy Consent Form (PDF Format)

Teletherapy Link 

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Jacqueline (Jak) Berg
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Jacqueline L. Berg
(603)387-1523
36 Country Club Road, Unit 823
Gilford, NH 03249

 

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