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MTPNW
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MTPNW
MTPNW
Announcements
Documents
Team
Training & Ed
Calendar
Referrals
Login Account
Announcements
Documents
Team
Training & Ed
Calendar
Referrals
Login Account

Intake/ Working Documents:

In Case of Emergency

Individual Rights Policy

MTPNW Practice Policies

HIPPA Form

Grievance Form

Grievance Policy

Consent for Audio/Visual Recording

Consent for Telehealth

Individual Intake

Good Faith Estimate (adjust cost)

Credit Card Information

Informed Consent for Psychotherapy

Phone Intake Form

Couples Intake Form

Group Intake Form

ACE Questionnaire

Sample ROI (use this no matter what)

New/ Discharging Client Form for Annie

Direct Deposit Form

W-2 Form

Worksheets for Clients:

Dyadic Adjustment Scale

Gender Unicorn

Feelings Wheel

Documents for Therapists

Safety Plan Template

Columbia Suicide Risk Assessment

Working with Child Consciousness

Hakomi 4 Step

Emotional Support Animal Letter

Inducing Mindfulness for Clients

4055 SW Garden Home Road
Portland Oregon 97219
(503) 766-4000
info@mindfultherapypnw.com
www.mindfultherapypnw.com
Jennifer D. Samsom, MA, LPC, LMHC, Executive Director 
Veronica Valenzuela, LPC, co-Director 
Kelly Hirstein, LPC, Clinical Supervisor