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African American Couple

New Client Forms

New Client Forms

For your convenience, our intake forms are available to print from the website. Choose the intake packet that is listed for your counselor and that is for the appropriate age bracket. For example, if you are seeing Jennifer and if the client is a child, print all forms from that section. Carefully read and complete the intake forms IN BLACK INK and bring them with you to your first appointment. Please bring all pages of the forms (not just the signature pages); we will be happy to give you copies of them if you wish. This will save a lot of time so we can make the best use of your first appointment!

*For couples counseling, each partner needs to complete his or her own intake packet.


Jennifer's Intake Packet for Adults (Age 18 and older)

Patient Health Questionaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Directions (if needed)


Jennifer's Intake Packet for Children (Ages 6 through 17)

Patient Health Questionaire - ages 12 and up only
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Directions (if needed)


Jennifer's Intake Packet for Couples* Counseling

Patient Health Questionaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gottman Permission Form
Directions (if needed)


Sarah's Intake Packet for Adults and Couples* (Age 18 and older)

Patient Health Questionaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Directions (if needed)


Sarah's Intake Packet for Teens (Ages 15 through 17)

Patient Health Questionaire 
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Directions (if needed)

 

Katie's Intake Packet for Adults and Couples* (Age 18 and older)

Patient Health Questionaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Directions (if needed)


Katie's Intake Packet for Teens (Ages 15 through 17)

Patient Health Questionaire - Ages 12 and up only
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Directions (if needed)

 

Emily’s Intake Packet for Adults and Couples* (Age 18 and older):

Patient Health Questionaire

Personal Disclosure Statement

Authorization to Release Information

Notice of Privacy Practices

Credit Card Payment Form

PHI Consent

Directions (if needed)

 

Emily’s Intake Packet for Children (Ages 8 through 17):

Patient Health Questionaire – ages 12 and up only

Personal Disclosure Statement

Child Development History

Authorization to Release Information

Notice of Privacy Practices

Credit Card Payment Form

PHI Consent

Directions (if needed)


Please note that Jennifer's office has moved. We have combined offices and the new location is:
6614 Shallowford Road Suite 250

Lewisville NC 27023