Email Me Today! [email protected] - Long Beach, California
JASMINE ADAMS, LCSW (SHE/HER)
  • About
  • EMDR Therapy
  • EMDR Training
  • EMDR Consultation
  • Services
    • Couples Therapy
    • Clinical Supervision
    • Intake Forms
  • Trauma Informed
  • Contact

Intake Forms

Please download, fill, and submit all forms 1 day prior to your first appointment by email ([email protected])


Adult Private Pay Intake Forms

Please fill out and submit all forms at least 1 day prior to your first appointment.

Adult Insurance Intake Forms (Cigna/MHN)

Please fill out and submit all forms at least 1 day prior to your first appointment.

Telehealth Consent Form
File Size: 13 kb
File Type: docx
Download File

adult_intake_questionnaire_2024.docx
File Size: 27 kb
File Type: docx
Download File

Individual Consent Form 2020
File Size: 27 kb
File Type: docx
Download File

PHQ-9 Form (English)
File Size: 37 kb
File Type: pdf
Download File

Generalized Anxiety Scale
File Size: 46 kb
File Type: pdf
Download File

Alcohol Audit
File Size: 34 kb
File Type: pdf
Download File

Telehealth Consent Form
File Size: 13 kb
File Type: docx
Download File

adult_intake_questionnaire_2024.docx
File Size: 27 kb
File Type: docx
Download File

Individual Consent Form 2020
File Size: 27 kb
File Type: docx
Download File

PHQ-9 Form (English)
File Size: 37 kb
File Type: pdf
Download File

Generalized Anxiety Scale
File Size: 46 kb
File Type: pdf
Download File

Alcohol Audit
File Size: 34 kb
File Type: pdf
Download File

Insurance Intake Form (MHN ONLY)
File Size: 35 kb
File Type: doc
Download File

Adult Release of info Insurance 2020
File Size: 27 kb
File Type: doc
Download File

 

Youth Intake Packet

Both the Youth and Parents must fill out the forms. Please fill out and submit all forms at least 1 day prior to your first appointment.

In case of custody situations, the caregiver affidavit needs to be filled

Telehealth Consent
File Size: 13 kb
File Type: docx
Download File

youth_intake_questionnaire-2024.docx
File Size: 26 kb
File Type: docx
Download File

Youth Consent Form
File Size: 23 kb
File Type: docx
Download File

Child Release of info Insurance
File Size: 19 kb
File Type: docx
Download File

PHQ-9 Form (English)
File Size: 37 kb
File Type: pdf
Download File

Generalized Anxiety Scale
File Size: 46 kb
File Type: pdf
Download File

Caregiver Affidavit Form
File Size: 21 kb
File Type: pdf
Download File

Insurance Intake Form (MHN ONLY)
File Size: 35 kb
File Type: doc
Download File

Couples Therapy

Please fill out and submit all forms at least 1 day prior to your first appointment.

Telehealth Consent
File Size: 13 kb
File Type: docx
Download File

Consent For Treatment 2020
File Size: 23 kb
File Type: docx
Download File

Couples Counseling Initial Intake Form 2020
File Size: 149 kb
File Type: pdf
Download File

Long Beach, CA
3711 Long Beach Blvd.
​Suite 5039 90807 

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Why am I a good choice for you?

- Create a safe and supportive environment
-Aware of biases and judgements and strive to make a space that is judgement free.
-passionate in helping others create a positive change
-dedicated to empowering clients to be their "best" self
- committed to anti-oppression work and advocacy
 Licensed Clinical Social Worker #26038
Contact Me Today!
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