Theresa M Cukierski will be taking Maternity Leave December 18, 2017-March 19, 2018 and is currently unable to accept new or returning clients at this time. For more details please click on this link: Maternity Leave Information. Active Clients who have scheduled an appointment with the Interim Therapist MUST SIGN AND RETURN this Release of Information Form BEFORE the scheduled appointment. This form will allow the Interim Therapist to have access to your records.
If you're a new client, please complete the following forms and bring them to your first therapy session.
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:
Note: To download Adobe Acrobat Reader for free, click here.