Specialized Counseling for Infertility, Loss and Grief


Infertility, Grief & Loss Group and Workshop Registration

New Client Counseling & Art Therapy Forms

This may be the first time seeking support services for life challenges.  It takes courage to reach out for support regarding infertility, loss and grief.   It is common to have some apprehension prior to a first counseling session.  Informed Consent to Counseling form and information from the New Client Information & History Form will be reviewed in the initial session. Please complete the New Client Information & History Form and any Release of Information forms for providers you may like Chartreuse Center to contact regarding your counseling in preparation of the initial session.  The other forms are available here for you to reference and will be reviewed with you during the initial session.  Other assessments may be completed in the first session based on the nature of your issues to best understand how therapy may be of assistance for you.  The subsequent sessions will be tailored to meet your counseling needs and life goals.


New Client Information & History Form


Release of Information to Chartreuse Center from another Provider

Release of Information from Chartreuse Center to another Provider


Informed Consent to Counseling     


Art Therapy Agreement


Client Rights   


Notice of Privacy Practices


Credit Card Authorization Form​​​​​

Click on the type of programs you would like to register and you will be linked to online registration.  All forms go directly to Julie Blackburn, LCPC, NCC, ATR at Chartreuse Center and will be processed with confidentiality. 


Infertility and After Treatment Groups & Workshop Registration


Grief Groups & Workshop Registration


Pet Loss Workshop Registration