​Forms

Adult Intake Form

Adolescent Intake Form



If you are 18 or older please fill out this form and bring it to your appointment. Please refrain from emailing this form because email does not guarantee confidentiality




If your child is 10-17 please fill out this form and bring it to the appointment. It is important for the guardian and not the child to fill out this form.

If the child is affected by divorce or any custody order is issued, I am required to review the order prior to Counseling treatment.
Download
Download

Informed Consent

Client Information



Please review and fill out this form which details counseling services which I offer. This form will be discussed during your first appointment
This form helps me know more about you, or your child and Counseling needs. Please fill it out and bring it to your first appointment.
Download
Download

Permission to Treat

Cancellation Policy



In the state of Texas I'm licensed to diagnose and treat mental health conditions. Please read the other forms by following the links in the next 4 catagories and acknowledge having read and understood these forms and understand treatment. If you have concerns contact me. 
Please acknowledge receipt and understanding of this form in the Permission to Treat form.
Download
Download

Credit Authorization Form

What to Expect from a LPC



Please complete this form and turn it in at your first appointment
Please acknowledge receipt and understanding of this form in the Permission to Treat form.
Download
Download

Limits of Confidentiality

Permission to use these forms with some modifications was provided by the kindness of my friend and mentor  MARIE DENISE GUILLORY, M.ED. LPC.



Please acknowledge receipt and understanding of this form in the Permission to Treat form.
Download