Client Forms

If you have made your first appointment, please find the appropriate forms below as was indicated to you by your therapist. These forms should not be filled out and sent until after you’ve spoken to Dr. Swartout to discuss your needs and you know which forms to fill out. Please call 602-980-9313, if you need more information.

The forms are fillable PDFs. Please click on your forms below to download them to your device, then fill them in fully. When complete, please email them to DrIlyssa@yourgrowingedges.hush.com, making sure to press the Encrypt button.

• Client Information
• Client Information Form (Insurance)
• Psychotherapist-Patient Services Agreement
• HIPPA Privacy Practices Notice
• Telehealth Agreement
• Payment, Client Balance, and Credit-card Policies
• Notice of Good Faith Estimate
• Good Faith Estimate
• Life History Questionnaire
• Columbia Suicide Severity Rating Scale
• Social Media Policy
• Adult General Symptom Checklist
• Couples/Partner Forms:
  • Couples Counseling Service Agreement
  • Couples Questionnaire
  • Dyadic Adjustment Scale (DAS)
  • Informed Consent for Participants in Couples Therapy
• Therapy Collateral Agreement
• Informed Consent for Intended Parents
• Fertility Health History for Intended Parents

Couples Homework – to be completed for your first session: It is important that we do not ONLY focus on the hurtful/negative aspects of your relationship.

1. Describe the relationship you would like to create.
2. What do YOU need to do/change to become a more effective partner?
3. How or why would this be difficult for you?
4. How motivated are you to make that change?
5. What is your level of motivation to work on your personal difficulties?
6. If you know that you are breaking up, what do you need to do to split most effectively so that the least amount of wounding will take place?

Please read the following two articles before your first session:

• 4 Reasons Communication Won’t Save Your Marriage
• How to Get the Most Benefit From Couples Therapy