New Client Forms

If you are a new client, please fill out the following intake forms before our first session and fax them to me (215-893-3081) or email them to me (

Client Intake Form

HIPAA Disclosure

Informed Consent for Telepsychology

If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

Authorization for Release of Information

If you are going to have hypnosis or hypnotherapy, please also fill out the following form.

Informed Consent For Hypnosis

intake forms

Contact Us

Please use the form on this page to send a message. Feel free to call or email anytime.

Fill out my online form.

© Dr. Bruce Eimer PHD LLC - All Rights Reserved | SEO James - Boca Raton SEO