|Mary Guzik MSW, LCSW
5050 Sunrise Blvd., Suite C-5
Fair Oaks, Ca. 95628
Copyright 2011 Mary K Guzik
This site contains documents that are in PDF format. Adobe Acrobat Reader, or an equivalent reader is
required to view and print them. A recent version of Acrobat Reader may be required. If you have problems
with Acrobat Reader or our PDF form, select PDF Troubleshooting.
The following forms can be filled out on your computer.
Each person attending therapy needs to complete an Intake Form before attending his/her first therapy
Authorization to Release and/or Exchange Information:
Protecting your rights to confidentiality is paramount (barring the exceptions where the law requires a
therapist to breach confidentiality). However, there may be a reason you may want me communicate with
another person. For example, you may wish to have me speak with your doctor regarding medications. In
the event you would wish for me to speak with a third party, you will need to fill out an Authorization to
Release and/or Exchange Information.
When a child is attending therapy, a Developmental History form needs to be filled out on his/her behalf.
This assists me in gaining a better understanding of the child’s history and current life. In addition to
filling out this form, I will need to speak with the parent/guardian to augment the developmental