Forms

The following forms must be completed and submitted prior to being scheduled with your clinician along with a photo of your government ID (driver’s license, etc.) and insurance card. After the forms are completed, please print, sign, and email them to ryan@reflectivecounseling.net

Intake Forms

  1. Client Questionnaire
  2. Communication Permissions
  3. Informed Consent Agreement
  4. Teletherapy Consent
  5. Teletherapy Emergency Plan
  6. Release to File Insurance Claim
  7. Therapy Financial Agreement
  8. Card Agreement
  9. HIPAA Consent Form

Release of Info

Release of Information

If you would like to have your provider communicate with any individual, organization, school, or medical provider, a Release of Information Form (ROI) must be completed for each individual entity you are permitting your provider to contact (it is recommended that all Primary Care Physicians, Schools, Psychiatrists, and Spouses have an ROI. It is also a requirement that any potential client under the age of 18 complete an ROI for their legal guardian prior to the initial session).

Download All Above Forms

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