Intake Forms

Intake Forms

Please print off, fill out, and bring these forms to your intake session.

• Client Information
• 
• All clients
• Privacy notice
• 
• All clients print off page one only
• Disclosure statement
• 
• All clients print off page one only
• Adult intake
• 
• All clients 18+
• Adolescent intake
• 
• Clients age 13-17 complete themselves
• Child/Adolescent intake
• 
• Parents/Guardians complete when client is a minor
• Infant Attachment Checklist
• 
• Infant Checklist
• Attachment Checklist Under 5
• 
• Children Under 5
• Attachment Checklist Over 5
• 
• Children Over 5
• Release of Information
• 
• For Coordinating Care
• Insurance verification
• 
• All insurance clients
• Authorization to disclose PHI to insurance
• 
• All insurance clients

You are welcome to come to your intake appointment with questions about how counseling may benefit you or your child.