Forms for New Clients

Name: Mindful Street and Anxiety Management
Price range: $$

Intake Forms

If you’re a potential new client, first get in touch with Harold Kirby for a consultation. After scheduling an appointment with Harold, please complete the following two forms and bring them to your first therapy session:

Client Psychotherapy Intake Form
Limits of Confidentiality/Therapy Cancellation Policy

Additional Forms

Group Therapy: If you are participating in one of the MSAM groups, please also complete the online Group Registration form in addition to the two forms above.
Coordinated Care: If you would like to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this additional Information Disclosure form to authorize release of psychotherapy information.

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