Timothy D. Stein, Marriage & Family Therapist

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Forms

Initial Client Forms (Intake)

Intake Packet (pdf)
Insurance Agreement (pdf)

Other Forms

Authorization to Release Protected Health Information (pdf)
Credit/Debit Card Pre-Authorization (pdf)

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Timothy D. Stein, MFT
1101 College Avenue, Suite 230 ¨ Santa Rosa, CA 95404
(707) 328-3425 ¨ TimSteinMFT@Yahoo.com ¨ www.timsteinmft.com