Amanda Jones, LCSW-S | SimplePractice

Who would be receiving care?

My partner and me

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Administrative

🌷Welcome

Please share a little about what brings you here so I can understand your needs and help guide next steps.

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🌸 Referral Source

How did you hear about my practice? ✨

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📁 Records Requests (If you are not requesting records, leave this field blank.)

I understand that: • A signed Release of Information (ROI) is required before any records can be released • Former clients must upload a government-issued photo ID to verify identity • I will be invited through the secure client portal to complete the ROI and upload my ID • Once identity is verified, records are shared through a time-limited, password-protected secure link • Records are accessed only through the secure portal and are not sent by email, text, or social media • To avoid delays, my ROI must include: the full name of the provider or practice receiving records, a secure email address for the recipient, and any specific limitations such as dates of service or document types

I have reviewed and understand the records request process

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.