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Forms

To save time on your initial visit, please print out and complete the two forms below:

(You will need an Adobe^® Acrobat reader to view and print out the forms. If you do not have a reader, or are having trouble printing out the form, you can obtain a free and current copy through this link.)

Client Intake Form (pdf file; 16K) This form provides me with some general background information and contact information.

Client Consent Contract (pdf file; 17K) This Agreement is intended to provide you with important information regarding the practices, polices and procedures and to clarify the terms of the professional therapeutic relationship between Therapist and Patient.

Optional Forms: These forms may be required. If either, or both, are needed, I will let you know.

Consent to Release Confidential Information (pdf file; 13K) This form gives the therapist written authorization to share your confidential information.
Telemedicine Informed Consent Form (pdf file; 12K) This form gives the therapist written authorization to provide health care delivery using interactive audio, video, or data communications (For example, telephone consultation).
“No Secrets” Policy for Family Therapy and Couple Therapy (pdf file; 82K) This written policy is intended to inform you, the participants in family therapy or couple therapy, that when I agree to work with a couple or a family, I consider that couple or family (the treatment unit) to be the patient.

Updated 5/8/12

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Mary M Buxton LCSW, Inc. - Sex & Couple Therapy - Licensed Clinical Social Worker #LCS 7780
3425 S. Bascom Ave., Suite F, Campbell, CA 95008 - Phone: 408.371.4847 - Email Mary