Welcome to Harvest House Counseling

We are glad to have you here!

If you are a first time client and have scheduled an appointment with us at either Watertown, Fulton, Syracuse, or Ithaca, we would like to welcome you to our practice. In order to make the most of our time together, we would like to invite you to fill out paperwork before you come into your first appointment. If you would like to do it now, please feel free to submit your information in the forms below and it will be automatically be sent to us electronically. If you would rather do it when you arrive, that is certainly an option.

We hope this is helpful and we look forward to meeting with you!

As always if you have a question, please give us a call at 315-663-7060.

Forms

Client Information Form

Client Information Form

  • If there is a second person attending the session, please fill out the following. If not, please go to the final section.

  • If you are using POMCO or EBS RMSCO/Lifetime Benefit Solutions insurance, please fill out the following

  • Acknowledgement and Receipt

    By submitting the below I acknowledge that I have read and fully understand the following: I have full access online to the following forms. I understand that I can request a hardcopy of the following forms and it will be provided by Harvest House. I understand that I have the right to discuss thoroughly and ask any questions about the forms with my Provider: Informed Consent for Psychotherapy (updated March 23, 2015) HIPAA (updated December 4, 2013) Harvest House Marriage and Family Therapy, P.C. uses and accesses technology including but not limited to: internet, email, voicemail, cellular phones, wireless phones, texting, facsimiles. Harvest House works to ensure that electronic information is protected from computer viruses and kept confidential from unauthorized intruders. Reasonable security measures are taken but confidentiality can not be assured. If you would like to not be connected by email or texting, please indicate below. Further, you agree not to contact me in this manner but will rely on phone or in person contact. If you do contact me via email or texting, you understand that this constitutes a revocation of any request from you to not use this form of communication.
  • *If there are going to be 2 clients working with us. If not put N/A
  • 8 + 8 =