Forms

There are both print and fillable versions of certain forms. If you are using the fillable version you need a PDF reader such as Adobe Acrobat Reader, and you must download the PDF form(s) first. Select File > Export As PDF > and add your name to the document file name and save to your desktop. Fill out the form and then save the file. Attach the forms to an email, include the name of the therapist they are for in the subject line, and email to: info@ftisb.org. 

1. Intake Form (print version) –  Click here If you would like to print out the intake form, fill it out and  bring it with you to your first appointment.

1. Intake Form (fillable version): Click here If you would like to fill out the intake form online, and email it before your first appointment.

2. Client-Therapist Agreement (print version) – Click here if you would like to print out the client-therapist agreement form, fill it out and bring it with you to your first appointment.

2. Client-Therapist Agreement (fillable version) – Click here If you would like to fill out the client-therapist agreement online, and email it before your first appointment.

3. Telehealth Consent Form (print version): Click here if you would like to print out the consent form, fill it out and bring it with you to your first appointment.

3. Telehealth Consent Form (fillable version): Click here If you would like to fill out the consent form online, and email it before your first appointment.

4. Good Faith Estimate Form (print version): Click here if you would like to print out this form, fill it out and bring it with you to your first appointment.

4. Good Faith Estimate Form (fillable version): Click here if you would like to fill out this form online, and email it before  you your first appointment.

5. Consent to Video & Zoom Participation (print version): Click here if you would like to print out the consent form, fill it out and bring it with you to your first appointment.

5. Consent to Video & Zoom Participation (fillable version): Click here If you would like to fill out the consent form online, and email it before your first appointment.

6. Consent Form for Alternate Communication (print version) – Click here if you would like to print out the consent form for alternate communication, fill it out and bring it with you to your first appointment.

6. Consent Form for Alternate Communication (fillable version) – Click here If you would like to fill out the consent form online, and email it before your first appointment.

7. Recurring Payment Authorization Form – Click here if you like to set up automatic payments for counseling sessions with your therapist, fill it out and bring it in to your next appointment or submit by email.

8. Authorization to Release Medical Information (print version) – Click here if you would like to print out the consent form to allow the Family Therapy Institute of Santa Barbara to access or exchange mental health records and information obtained during the course treatment.

8. Authorization to Release Medical Information (fillable version) – Click here If you would like to fill out the release form online, and email it before your first appointment. This allows the Family Therapy Institute of Santa Barbara to access or exchange mental health records and information obtained during the course treatment.

9. Questions To Ask Your Insurance Company – Click here to see an outline of questions to ask your insurance company. The benefits for therapy are usually different than your typical medical coverage. Prior to attempting to make an appointment with a therapist, contact your insurance company and obtain the following information.

10. Current Family Assessment – If you would like, click here for a brief test that will help you to learn your family’s strengths and areas for growth. Print it, fill it out, score it and discuss your results with your therapist.

11. Family of  Origin Assessment – Click here for a brief test that will help you to learn your family of origin’s strengths and weaknesses. Print it, fill it out, score it and discuss your results with your therapist.

12. Notice of Privacy Practices | Patients Rights & Responsibilities – Click here to read the Notice of Privacy Practices as well as Patient Rights & Responsibilities form.