General Information

Communication Information

Occasionally, it will be necessary for our office to contact you regarding matters about counseling. This permission form will help us know when and how to contact you in ways which are comfortable for you.

By giving permission for use to contact you in one or more of the ways listed below, you are agreeing for us to leave messages and information. We will always try to be discreet in any messages we leave, but we cannot guarantee confidentiality once the message is left.

In order for you to get access to our Client Portal we must have an email.

Depending on the type of Reminders you select below, we need a cell phone and/or an email.

Parent/Legal Guardian Information

Insurance Information

You are required to obtain a letter in advance from the person or agency which includes an address for statements, name of person responsible, and number of visits authorized. (There will be a place to upload it when completing your new client paperwork)

Please enter any insurance you might wish to use after the above person or agency allowed visits are complete in the Secondary Insurance section below:

Therapist or Clinician Information

Please answer the following to help us get you scheduled: