New Client Profile – Counseling

  • Contact Information

  • NamePhone 
  • Personal Information

  • NameAgeRelationship 
  • Please provide their contact information and sign the following release if I will be coordinating care with them: Mutual Exchange of Information
  • SubstanceAmount 
  • Authorizations

  • Consent for Treatment

  • Consent for Treatment of Children and Adolescents:

  • Signature

  • By signing this form, you are agreeing that all information is true to the best of your knowledge.
  • This field is for validation purposes and should be left unchanged.