New Patient Information

Please click on the links below to access and download any documents as PDFs.
Please complete all relevant forms in advance of your first appointment, and bring them with you or fax them to us at 703.361.1540. We realize this is an significant amount of paperwork, but by completing the forms before the appointment you will get the most value from your session.

Please bear in mind that, in accord with ethics rules, therapists can only provide services within the scope of their training and experience. If Quarternote Counseling is unable to met your needs, we will gladly provide you referrals to other appropriate service providers.

All clients (or if under 18 their parent/guardian) will need to complete the Patient Registration Form. If a client is under age 18, a parent or guardian will need to sign where signature is required. An adolescent client will need to complete the “Adolescent Intake” form, and their parent or guardian will need to complete the  “Adolescent Intake for Parent/Guardian.” Clients age 18 or older are asked to complete the “Adult Intake Form.”

If you do not have insurance, or have an insurance that Quarternote Counseling does not accept currently, please feel free to review and complete the sliding scale form. We currently accept Aetna; Anthem (including Health Keepers); Care First (including Blue Choice); InTotal Health; Magellan, and; Medicaid. If you have any questions, feel free to call us on 703 675 5361. To fully protect client confidentiality, we do not use email.

Thank you.

Patient Registration

Adult Intake Form

Adolescent Intake Form (Completed by Adolescent)

Adolescent Intake Form (for Parent or Guardian)

Sliding Scale Chart and Form