Gina Allison, MSCP, LPC, QMHP
Inner Active Wellness, LLC
Gina Allison, LPC-#C2507
541.329.0555
390 First St. Suite 2B
PO Box 1387
Bandon, OR 97411
gina@ginaallisontherapy.com
Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

  • Client Psychotherapy Intake Form
  • Limits of Confidentiality/Therapy Cancellation Policy

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form

Client Psychotherapy Intake Form  
Limits of Confidentiality/Therapy Cancellation Policy  
Authorization to Disclose Information Form  

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