Client Resources

Forms

New Client Packets (PDF Form)

 

 

New Client Packets (PDF Form)

  • Individual Therapy Packet for an Adult

  • Individual Therapy Packet for a Conserved Adult

  • Individual Therapy Packet for a Child or Minor Adolescent

  • Individual Therapy Packet for a Minor Adolescent (14+) consenting for self

  • Couples Counseling for two Adults

  • Joint Therapy for an Adult and a Minor Child

  • Joint Therapy for two Adults

  • Joint Therapy for a legal Adult and a Conserved Adult

  • Family Therapy

 

Individual Forms (PDF Forms)

  • Informed Consent and Confidentiality Agreement

  • Intake for Mental Health Service for an Adult

  • Intake for Mental Health Services for a Conserved Adult

  • Intake for Mental Health Services for a Minor

  • Intake for Mental Health Services for a Couple

  • Intake for Mental Health Services for a Family 

  • Consent for Treatment for an Adult

  • Consent for Treatment for a Conserved Adult

  • Consent for Treatment for a Minor

  • Privacy Practices

  • Release of Information

Telehealth Portal

Doxy.me Virtual Office

Submit a Payment

The fee for service is $135.00 for a 50 minute session, although we may take up to the full hour. 

Currently, I do not accept insurance. However, those with out-of-network benefits will be provided with a receipt for services (commonly known as a "superbill") to receive reimbursement. 

Credit card, check (payable to IGNITE), cash, PayPal (info@ignitefutures.org) and Venmo (@ignitecollective) are accepted.

 

Contact Me

For any questions you have, you can reach me here:

Tina Ebsen MA LMFT ATR

810 Lawrence Dr. Suite 100
Newbury Park, CA 91320

 

805.500.6597

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© 2020 Tina Ebsen MA LMFT ATR