Phone (618)
527-6144
Forms
This page is under construction
Below you will soon find links to a variety of forms for existing and new clients. Many of these forms are available as either secure, web-based forms or as files for you to download and print. Check back soon when this page is complete.
For now, only use these forms if instructed to do so on the phone or in person.
| Form Name (click to access online version if available) |
Word Document |
PDF Document |
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Client Information Form |
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Agreement to Pay for Services and Assignment of Benefits |
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Authorization/Release of Records |
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Credit Card Authorization (return by fax if not comfortable using Paypal) |
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Consent to Treatment of Adolescent |
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Consent to Treatment for Couples |
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Consent to Treatment for Individuals |
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Cover Sheet for returning forms by fax |
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Acknowledgement for Receipt of Notice of Privacy Practices and Consent to Use Information |
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Parent Agreement for Adolescent Therapy |
Check Back for Updates
