• Connie P. Edens LCSW LLC | 485 B Carlisle Drive, Herndon, Virginia 20170 | Phone: (571) 306-2334

Forms

Below you will find four forms – the Information for New Clients Form, the Intake Form, the HIPAA Notice of Privacy Practices, and the Receipt of Notice of Privacy Policy Form.

Click on the forms below to view and download them. Please review, complete, and sign the Information for New Clients, Intake, and the Receipt of NPP forms and bring them to your first appointment. For couples, each partner needs to complete a separate Intake Form.

If it doesn’t work for you to print and complete the forms before your appointment, please contact Connie so she can have the forms ready for you and then plan to arrive 20 minutes before your first appointment.

Information for New Clients

Screenshot of New Client Form

Intake Form

screenshot of Intake Form

HIPAA Notice of Privacy Practices

* This form is for clients to keep. You do not need to bring a printed copy to your appointment.

Screenshot of HIPAA Form

Receipt of NPP

Screenshot of Notice of Privacy Practices Receipt Form