Forms 2017-03-31T09:16:48+00:00

Forms for your first visit

You can download forms to bring with you to your first visit and save time in the waiting room. We can always provide them for you when you come, but you may want to come a few minutes early.

Intake Forms for Abigail Burd, LCSW
To read and keep for your files: “Notice of Privacy Practices”:
Notice of Privacy Practices_Abigail Burd, LCSW

Please PRINT, COMPLETE AND BRING WITH YOU: “Receipt and Acknowledgment of Notice”:
Receipt Acknowledgment Of Notice_Abigail Burd,LCSW

and “Client Information Form”:
Client Information_Abigail Burd, LCSW.

Optional form that may be useful.
If there is another professional or a family member that you would like me to be able to talk to, this “Release of Information” form may be needed:
Release of Information_Abigail Burd, LCSW

We may ask you to complete one or more of these questionnaires:
Depression screen: PHQ-9
Anxiety screen: GAD-7
If you are pregnant or have a baby under 12 months old: EPDS

CONTACT

Your Name (required)

Your Email (required)

Phone Number

Subject

Your Message

By checking this box (required), I certify that I have read this statement and agree to its terms: If you are considering harming yourself or someone else or are in need of IMMEDIATE crisis counseling assistance, please call the San Diego Access & Crisis Line at 1-888-724-7240, 24 hours a day/7days a week. For life threatening emergencies, please call 911. The use of email or this form for communication does not establish a therapist-client relationship. Confidential or time-sensitive information should not be sent through this form.

Burd Psychotherapy
5252 Balboa Ave #803,
San Diego, CA 92117

619 289 7818

Monday  9am – 8pm
Tuesday  9am – 5pm
Wednesday  9am – 5pm
Thursday  9am – 8pm
Friday  9am – 5pm
Saturday  9am – 5pm
Sunday  closed