Download Forms

Before our Intake Assessment session, please follow these instructions:
- Read the Clinician Disclosure form and print or save it for your records if you desire.
- If you want online sessions, read the Telemental Health Informed Consent form and print or save it for your records if you desire.
- Read the Notice of Privacy Practices form and print or save it for your records if you desire.
- Print the Intake form. Complete it and sign it.
- Print the Signature form. Complete it and sign it in five places (or six, if you desire online sessions). Please note: If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).
- Print the Billing form and sign it.
- Photograph both front and back of your insurance card.
- Return the Intake form, the Signature form, the Billing form, and the images of your insurance card to me by one of the following methods.
- Fax the forms to 360-504-3984.
- Scan or photograph the forms and attach them to an email using KimYkemaCounseling@gmail.com.
- Mail the forms to my office: Kim Ykema Counseling PLLC, 908 Georgiana Street, Port Angeles, WA
After I receive the signed forms, I will contact you to confirm our Intake Assessment appointment.
I know that paperwork can be confusing. If you have any questions, please contact me. Contact