I am an ALGBTQ+, Sex Positive, Kink / Polyamory / and Consensual Nonmonogamy Safe and Sensitive Provider.
I am also an American Association of Sexuality Educators, Counselors, and Therapists (AASECT) certified sex therapist.
Individual Therapy Intake Forms
Individual Therapy Intake: This is an intake packet for people interested in individual counseling who will be using insurance.
Individual Therapy Intake (Self Pay): This is an intake packet for people interested in individual counseling who will NOT be using insurance.
Individual Therapy Intake (Sliding Scale): This is an intake packet for people interested in individual counseling who have an agreed upon sliding scale.
Telehealth Informed Consent (Individual): This document goes over information related to telehealth services including relevant boundaries, installation instructions, risks, and benefits.
Couples Therapy Intake Forms
Couples Therapy Intake: This intake packet is for couples therapy.
Telehealth Informed Consent (Couples): This document goes over information related to telehealth services including relevant boundaries, installation instructions, risks, and benefits.
Notice of Privacy Practices & Informed Consent: This is a form that covers your privacy rights, informed consent, and policies.
Release of Information: This form is used if you want me to have contact with somebody else regarding your services.
Release of Information (W/ Progress Notes): This form is used if you want me to have contact with somebody else regarding your services. This form is only used when you want progress or psychotherapy notes to be disclosed
Credit Card Authorization: This is a form if you want to leave a credit card on file.
Safety and Coping Information
Technology Safety Recommendations: In the era of technological breaches, these data security recommendations can be helpful to protect your privacy online.
Coping During COVID 19: Based upon a training I attended recently, I have put together some suggestions for coping during the COVID 19 pandemic.
Consent for in-person Services During COVID-19: This form is only for specific clients for whom services cannot be adequately performed via telehealth. If we have discussed that you meet these criteria and have agreed upon meeting in person, carefully reviewing and signing this form will be required prior to our first in-person appointment.
HIPAA Privacy Officer Information
If you have any concerns about privacy, please feel free to contact the Families First Therapy designated HIPAA Privacy Officer, Stephen Ratcliff in person or via the following: Telephone (505) 504-5449; Fax (844) 840-7345; Email
email@example.com; Mailing Address: PO BOX 35937 Albuquerque, NM 87176; or in person at your next appointment.
Non Discrimination Policy
Families First Therapy is an equal-opportunity provider. Families First Therapy prohibits discrimination and harassment based on kink, relationship configurations (e.g. polyamory, swinging, open, etc.), race, ethnicity, creed, religion, sex, national origin, citizenship, marital status, age, disability, sexual orientation, gender identity and gender expression, veteran status, or any other status protected by applicable law to the extent prohibited by law. Families First Therapy provides an atmosphere of respect, dignity, acceptance and safety for all clients. Furthermore, no client will be discriminated against based on referral source. Families First Therapy is open to clients from a number of referral sources including, but not limited to, self-referrals, juvenile probation referrals, child protective services referrals, referrals from primary care physicians, and both public and private health insurance based referrals.
Complaint Policy and Procedure
If you are unsatisfied with the services you have received at Families First Therapy, I welcome you to inform me in person. I consider it a gift if you bring up your concerns so I can make amends if need be. However you may also address a written compliant to:
Families First Therapy, LLC
PO BOX 35937
Albuquerque, NM 87176