Intake Form

C Jessica Hersch, LCSW, LMFT
Child & Adult Counseling | Marriage & Family Therapist

115 N College Ave #113, Bloomington, IN 47404
phone: 812-332-8814
email: jherschtherapy@gmail.com

Intake Forms

📄 HIPAA Privacy - Available if needed.
Download our 📄 intake form (Microsoft Word) , complete it, and then email to jherschtherapy@gmail.com.
📄 Release of Information - Available if needed.
📄 Telemental Health Informed Consent