Dr. Leah B. Samler LLC

Dr. Leah B. Samler LLCDr. Leah B. Samler LLCDr. Leah B. Samler LLC

Dr. Leah B. Samler LLC

Dr. Leah B. Samler LLCDr. Leah B. Samler LLCDr. Leah B. Samler LLC
  • Home
  • About Therapy
  • Education and Background
  • Services
  • Mind Body Medicine
  • Training
  • Contact
  • Media
  • Forms
  • Resources
  • More
    • Home
    • About Therapy
    • Education and Background
    • Services
    • Mind Body Medicine
    • Training
    • Contact
    • Media
    • Forms
    • Resources
  • Home
  • About Therapy
  • Education and Background
  • Services
  • Mind Body Medicine
  • Training
  • Contact
  • Media
  • Forms
  • Resources

Initial Appointment Forms

Please complete all forms and email them prior to your first appointment to: info@drleahsamler.com.  All email communication is HIPAA compliant and encrypted. 

Intake Information (1) (docx)

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Informed Consent for Therapy Services (docx)

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Consent for Release of Information (docx)

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Insurance Information (docx)

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Cancellation Policy (doc)

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Continuity of Care Fees (docx)

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HIPPA ROI (docx)

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Notice of Privacy Policy (docx)

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Credit Card Authorization Form (docx)

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Copyright © 2018-2021 Leah B. Samler, Psy.D. - All Rights Reserved.

 Photo of Dr. Samler courtesy of Jovanka Novakovic www.bauwerks.com 


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