Therapy Forms

Please print and fill out forms #1 through #4, and bring them to your first appointment with you. Thank you!

1. Personal Information Form
2. Signature on File
3. Informed Consent
4. HIPAA Signature Sheet
5. HIPAA Notice (read only)
6. Release of Information (to be printed if requested)


805-623-4177  |  Santa Barbara, CA    

Jill Rubin, LICSW, Psychotherapist, Life & Relationship Coach

Jill Rubin, LCSW
Relationship Coach

Helping you live the life you desire, through relationship coaching and psychotherapy.

Book a free consultation
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