Forms

If you would like to fill out your paperwork prior to your first session please feel free to print the following documents and bring them with you:


Intake Information form

This form is required for all new clients. If you are a parent filling this out for a child please make sure it is the child's information that you use on this form.

 

Release for Insurance Billing

This form is necessary so that I may share your information with your insurance company for billing purposes. Any child over the age of 12 must sign in addition to their parent or guardian. If you are not using insurance you do not need this form.

 

Basic Information and Treatment Agreement
Basic Information and Treatment Signature Form

Please print and read the document and then print and sign the accompanying signature form. Any child over the age of 12 must sign in addition to their parent or guardian.

 

Notice of Privacy Practices
Notice of Privacy Practices Signature Form

Please print and read the document and then print and sign the accompanying signature form. Any child over the age of 12 must sign in addition to their parent or guardian.

 

Electronic Communication – Client Copy
Electronic Communication – Office Copy

Please print and save the Client Copy for your own records, then print and sign the Office Copy.

 

Intake Questionaire Adult
Mood Assessment Adult
Intake Questionaire Teen
Mood Assessment Teen

Please print and fill out the appropriate form for your age. Teen for anyone under 18 and Adult for anyone over 18.

 

Release of Information for Other Professionals

If you have anyone such as a psychiatrist or school counselor whom you would like your therapist to be able to speak with.

 

Home About Services Resources Contact
Frequently Asked Questions
Forms
Instagram
YouTube
Yelp
LinkedIn
Google Plus
Facebook
© 2013-2017 Evans Counseling. All Rights Reserved.