Judith Smithchild - M.Ed., LPCC-CS, LICDC-S, NCC
                  INTAKE FORMS
 
For an INDIVIDUAL counseling intake packet, you will need to download eight (8) files:
 A biographical form, medical release, confidential release form for your emergency contact person, billing information sheet, HIPPA notice, and Office Policies form.  Print out all of the forms, completely fill out, and then bring them with you to your intake session. An intake session cannot proceed unless these are completed.  You may drop them off at the office a few days before your appointment if you wish but they must be done prior to the session.  You are welcome to come to the office 30-45 minutes early to complete your packet in the lobby, just be sure to bring the forms with you to complete. You will be asked to reschedule the intake if you arrive at the appointment without the completed forms. 
 
 You are asked to also bring a copy of your current insurance card to the initial appointment, a photo identification, and any co-pay that you are responsible for. Only actual Cash payment or check are accepted. No change is kept on site. No debit or credit cards are accepted.

DIRECTIONS FOR THE FORMS COMPLETION:

DOWNLOAD AND PRINT OUT  ALL EIGHT (8) FORMS FOR INDIVIDUAL INTAKE OR EIGHT (8) FORMS FOR COUPLES INTAKE.
COMPLETE THE FORMS, ALL SECTIONS ARE TO BE FILLED OUT.

BRING COMPLETED FORMS TO YOUR INTAKE SESSION. THANK YOU!
 
INDIVIDUALS'S BACKGROUND FORM:








BILLING, MEDICAL RELEASE, OFFICE PRACTICES, CONSENTS:

Consent to Release.pdf (PDF — 8 KB)







HIPPA Notice.pdf (PDF — 72 KB)
 




            





  COUPLES COUNSELING  INTAKE FORMS



 
 
 
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