Please click the links below to access Danielle Jacobs LMHC’s Client Forms.

NOTE: These forms are password-protected, as they are meant only for use by Danielle Jacobs’ clients (she will provide the password as needed).

All Clients

Client Contract

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Client Contract (Court-Referred)

Only for court-referred clients.

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Credit Card Authorization Form

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Authorization to Release Information

OPTIONAL

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All Adult Clients

Concerns Checklist

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Relationship Survey

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The Burns Depression Checklist

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The Burns Anxiety Inventory

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Divorced Parents

Questionnaire for Divorced Parents

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Parents/Caretakers

Child Background Information

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Couples Counseling Clients

Relationship Worksheet

Additional worksheet for Couples Counseling clients

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Clients Interested in Hypnotherapy, EMDR or Past Life Regression

Hypnotherapy Consent Form

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EMDR Consent Form

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Past Life Regression Consent Form

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Other Forms

CAGE Questionnaire

The CAGE Questionnaire Adapted to Include Drugs (CAGE-AID)

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Contact Me

Contact me about my services and publications, or fill out the pre-screening form and I will contact you ASAP for a free phone consultation.