Nicoletti-Flater Associates, PLLP
Specialists in Police and Public Safety Psychology, Crisis Intervention, Trauma Recovery, and Violence Prevention
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Disclosure for Voluntary Referral
Disclosure for Mandatory Referral
Disclosure for Referral of a Minor Child
Authorization for Release of Information
New Client Forms

You will need Adobe Reader to download and print these forms. Please bring the completed forms with you to your first session.

If you have any questions regarding these forms, please do not hesitate to ask your therapist at the beginning of your first session.

*Please note that if more than one individual is being seen, a seperate Intake, HIPAA, and Disclosure form must be completed for each individual.
If you are a NEW THERAPY CLIENT with Nicoletti-Flater Associates, please complete the:

1) Intake
2) HIPAA and either:

3a) Disclosure for Voluntary Referral OR
3b) Disclosure for Referral of a Minor Child (if the client is 15 years old or younger) OR
3c) Disclosure for Mandatory Referral (if an employer has requested that the client attend counseling)


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