Krista Jana, Ph.D.
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Dr. Jana Forms
New Client Forms

If you have already scheduled an initial appointment, please print and complete the forms to the right, and email them to me or bring them to our first meeting.  (The telehealth informed consent need only be completed if you would like the option of meeting via telehealth.)




informed_consent_charlottesville_psych.pdf
File Size: 92 kb
File Type: pdf
Download File

telehealth_informed_consent_charlottesville_psychological_services.pdf
File Size: 209 kb
File Type: pdf
Download File

registration_form_charlottesville_psych.pdf
File Size: 71 kb
File Type: pdf
Download File

background_packet.pdf
File Size: 86 kb
File Type: pdf
Download File

For new couples therapy clients, each partner should complete the Couples_Therapy_ Questionnaire below in addition to the forms above:
couples_therapy_questionnaire.pdf
File Size: 73 kb
File Type: pdf
Download File

Existing couples therapy clients, see below for a copy of the weekly questionnaire for your files:  
weekly_questionnaire_for_couples_therapy.pdf
File Size: 49 kb
File Type: pdf
Download File

Release form for consultation with other care providers, family members, etc.:
release_form_charlottesville_psych.pdf
File Size: 75 kb
File Type: pdf
Download File

Krista Jana, Ph.D.                              (434) 227-6631                             700 Harris St., Suite 201C.  Charlottesville, VA 22903                                   dr.kjana@gmail.com