Lucinda Thimm-Jurado MSSW, LCSW

Forms Needed for Appointments

Please download and print the following forms, fill them out, and bring them with you to your appointment. They are in PDF format, and can be opened for printing with Adobe Acrobat Reader.

Click Here to Download Acrobat Reader

Registration Form
Please bring this registration form, along with your insurance card, to your first appointment. It is very important that it is filled out accurately so we are able to serve you better and process your insurance claims promptly.

Authorization for Release of Info
Please print and fill out the Authorization For Release Of Confidential Information And Records Form if you would like to request verbal or written disclosure of your medical records to an individual or agency.

Adult History Questionnaire  /  Teen History Questionnaire
Please fill out and bring this registration form to your initial appointment. It will make our time together more productive and allow me to best serve your needs. Together we will be able to generate solutions to address your concerns.

Child History Questionnaire
Parents, please fill out this child registration form prior to your child's initial appointment. It will help make our meeting as productive and informative as possible, and allow me to best serve your needs, generate solutions, and address your concerns.

Coping Skills Group for Teen Girls - Form for Parents
Parents, please fill out this form prior to your child's participation in the group. If the child / teen is currently a client with Luci, you may fax, e-mail, or send it to Luci prior to when the group begins. Please let her know as soon as possible that your child would like to attend the group. If the child / teen is not currently a client of Luci's, please call Luci to schedule an evaluation, prior to the group start date, to dertermine if the group is appropriate. Please fill out the registration form and child history questionnaire, along with the group form.

Coping Skills Group for Teen Girls - Form for Referrals
Please fill out this referral form for the Coping Skills Group, and have the parent sign the "Authorization for Release of Info" form (found above) to allow us to share information regarding their child / teen. Please fax or send forms by mail to Luci.

I look forward to meeting you, and working with you and your family. Thanks!