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Home
About
Services
New Clients
Get in Touch
New Clients
We make it super easy!
Download the forms below
Print the forms
Add your “John Hancock”
Bring to 1st Appointment
Download Consent Form
Download Consent Form Signoff
Download TeleHealth Consent Form
Download Privacy Practices
Download Privacy Practices Signoff
If you desire anyone to be aware of your counseling, please complete form and bring to first session. Only one person/entity per form.
Download Release of Information
Please fill out this form so we can better assist you
Full Name
*
Email
*
Date of Birth
*
Age
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone Number
Is it okay to leave a message?
Yes
No
hidden
Cell Phone Number
Is it okay to leave a message?
Yes
No
Is it okay to text?
Yes
No
Texting Disclaimer
*
I understand this disclaimer.
Texting will only be used to confirm or cancel appointments as it is not the most safe and confidential way to communicate. By checking "yes" you're stating that you're aware of the risks and agree to this manner of communicating.
Work Phone Number
Is it okay to leave a message?
Yes
No
What is your marital status?
*
Please select one
Married
Separated
Divorced
Single
Spouse Name
Children's Names & Ages
Do you have insurance that covers mental health?
Yes
No
Who is your insurance provider?
*
Is this your primary insurance?
Yes
No
What type of counseling are you seeking?
*
Individual Counseling
Couples Counseling
Family Counseling
Reason for seeking counseling
*
Scheduling Preference
*