Helpful Forms

Please print and fill out the below forms.

New Client Registration

New clients please print and fill out the following pages. Or you can fill out the form below.

Counseling Solutions Form

  • New Client Registration


  • Date Format: MM slash DD slash YYYY


  • Responsible Person Information (If other than the client)




  • Emergency Information




  • Insurance Information




  • Primary Insurance



  • Secondary Insurance



  • Please read and sign the following

    If you choose not to assign payments of benefits directly to your therapist, payment in full will be required at the time of service.
    I authorize the release of any medical or any other information necessary to process this claim. I authorize payments of medical benefits to my therapist. I also request payments of government benefits either to myself or to the party who accepts assignments as indicated on the insurance claim form.

  • Drop files here or
  • Date Format: MM slash DD slash YYYY
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