Jennifer Rossi, Ph.D.

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Required Documents

Prior to attending your first session, there are six documents that must be returned to my office by either fax or traditional postal mail (please do not email any of the documents, as email is not a secure form of communication for sensitive or private information).

Three of the documents that I require include:

  • Photocopy of Insurance Card (if applicable, both front and back).
  • Photocopy of Credit/Debit card, both front and back.
  • Photocopy of Valid Photo ID, such as drivers license or passport.

The other three documents that I require are in pdf format and are available for download.

Client Intake Form Therapy Consent
Financial Policy Statement

Client Intake Form: This is a standard, three-page form that I use to collect basic demographic information about you, become appraised as to your medical/cultural background, etc..

Therapy Consent: A one-page form that describes the framework of our professional relationship.

Financial Policy Statement: A one-page document that clearly describes your financial responsibilities upon entering therapy.

Also Please Note:

  • Fax all documents to 855-942-5721, or mail to PO Box 734, Reedsport, Oregon 97467.
  • And please ensure that your photo copied documents are completely legible (enlarge if neccesary).

© Copyright Jennifer Rossi, Ph.D.  Please note that the information that appears on this website should not be considered as any form of treatment.  If you are having an emergency, please call 911 or go to the nearest hospital.