Learn about The Chesnut Group's first conference: Tristate Eating Disorder Conference 2023

TheresaChesnut@TheChesnutGroup.com | (650) 206-4505
Contact Now Schedule an Appointment

Connect@TheChesnutGroup.com | (650) 206-4505

Client Forms

Client Forms

If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.

Client Intake Form

Information Sheet

Limits of Confidentiality

If you would like your therapist to collaborate with another provider, simply fill out the form below.

Authorization for Release of Information

Contact

180 2nd St
Los Altos CA 94022
(650) 206-4505

Evansville, Indiana 47713
(812) 221-2710

Connect@TheChesnutGroup.com

By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.