Judith Peletz
  • About
  • Services and Specialties
  • Fees and Insurance
  • Forms
  • Contact
Select Page
  • About
  • Services and Specialties
  • Fees and Insurance
  • Forms
  • Contact

To save time at your first appointment, you may print these forms and fill out to the best of your ability beforehand.  Thank you!

1. New Client Registration

2. Self Assessment Form

3. Treatment Agreement

4. Notice of Privacy Practices

5. Telehealth Counseling Agreement

6. Consent for Exchange and Release of Information

Judith S. Peletz, M.A. M.Ed - Licensed Marriage and Family Therapist - License No. MFC39578
1144 Sonoma Ave., Suite 104. Santa Rosa, CA 95405
Phone: (707) 526-7720 ext. 315
©Judith Peletz 2022. All rights reserved.