Embedded Files
We will also need a copy of a valid ID and your insurance card (front and back).
We will also need a copy of a valid ID and your insurance card (front and back).
Disclosure - please fill in your name and date of birth and sign/date the: Counselor Disclosure, Confidentiality and Privacy Notice, Participant Rights, Financial Agreement, No-show and Cancellation Policy; the Resources page at the end is for you to keep.
Emergency Contact - please designate an individual to be your emergency contact and fill out the form with their name, address, phone, etc
Consent for Release of Confidential Information - you may disregard if irrelevant, otherwise please fill out with the name/address/phone of anyone, with whom you wish I be able to communicate, make sure to initial any x-marked "____" relevant line
Voluntary Consent - please make sure to initial every "___" behind each statement
TB & HIV/AIDS screens - please fill out and sign
Screenings - please only complete the screenings you find relevant to your history, don't worry about scoring them
Crisis plan - this is an optional form
Supervisee Registration - if you are seeking clinical supervision, please fill out this form, as well as the Disclosure, Emergency Contact, and Voluntary Consent
*You can fill out, sign, and initial forms after you download them, by opening them in Adobe Acrobat Reader. If that program is not installed on your device, you can download it here.
Please call or email the provider with any questions regarding the forms.
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