Email to [email protected] with subject including " Telehealth "
Form must be signed in order to be accepted
If you are a New Client, please Read & Complete the following forms to the best of your abilitiy.
Bring the completed forms to your first counseling appointment, along with your Photo ID and Insurance Card. If you have any questions related to the paperwork, they will be addressed during the initial appointment.
If you do not have access to a printer, you may fill out the forms in office on the day of your appointment by arriving 15 minutes early before your scheduled appointment time.
Email is not a secure form of communication and we cannot guarantee confidentiality.
We advise against sending these completed forms with your protected health information (PHI) to us via email. Instead, we encourage you, if possible, to print out your respective form in order to read over and complete the form to bring with you to your first appointment.
- Forms for Adult - Individual Appointment
- Forms for Adult - Couples Appointment
- Forms for Minor - Child Appointment (For Parents to Fill Out)
If you have scheduled for Psychological Testing, you may print and complete out the respective form below to bring to your Evaluation Appointment:
- Forms for Adult - Testing Evaluation
- Forms for Minor - Testing Evaluation (For Parents/Guardians to Fill Out)
Primary Care Physician release of information forms are included in the above packets. If you would like to coordinate care with, or release information to, a third party (e.g. an attorney, a family member, a doctor other than your primary care physician), complete the respective form below and bring the completed form to your appointment to authorize release of your counseling information:
- CCCC Generic Release of Information Form (Adults)
- CCCC Generic Release of Information Form (Children-For Parents)
Note: To download Adobe Acrobat Reader for free, Click Here.
Again: Email is not a secure form of communication...we cannot guarantee confidentiality.
Services for Individuals, Couples, Children & Families