Family Life Counseling Services

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Form NameDescriptionLink
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Forms
Welcome LetterA letter for new patientsWelcome-Letter.pdf
HIPPA FORMPlease read Notice of Policies and Practices to Protect the Privacy of Your Health Information. Print page 8 and return signed with your intake forms. Thank You. Health Insurance Portability and Accountability Act See www.hippa.org for more information.HIPPA.pdf
Adult Intake Form PDFThis form can be filled out on your computer by double clicking the gray boxes and typing your answers in the proper field. Print out and bring with you to your initial session.Adult Intake Form 2013 Web grey.doc
Adult Intake Form This form can be printed out and filled in to bring with you on your first appointment.Adult Intake Form 2013 WEb.doc
Youth Intake Form PDFThis form can be filled out on your computer by double clicking the gray boxes and typing your answers in the proper field. Print out and bring with you to your initial session.Youth intake form 2013.doc
Child Intake Form PDFThis form can be filled out on your computer by double clicking the gray boxes and typing your answers in the proper field. Print out and bring with you to your initial session.Child Intake 2013.doc
Talking to your Children about their first visit to a PsychologistTalking to Children about their first visit to a Psychologist.Talking-to-Your-Child.pdf
Patient Release for Dr. DupereGeneral Consent FormConsent-form-for-DPD.pdf
Patient Release for Dr. SimpsonGeneral Consent FormConsent-form-for-DGS.pdf
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