Forms

For your first session please complete the new client intake form for counseling paperwork listed below AND arrive 15 minutes prior to your scheduled appointment to complete privacy paperwork. 

We charge an administrative fee of $40 per 45-50 minute session.  See our payment link to Northland Church for details. 

NEW CLIENTS 
If you are a new or returning client, please complete the following forms and bring them to your first counseling session:

• Client Intake Form for Counseling
• Consent to Telehealth 
• Informed Consent and Policies and Procedures
• Notice of Privacy Practice and Client Acknowledgement Receipt of HIPAA Practices

FINANCIAL ASSISTANCE 

If you are in severe financial hardship and are receiving help from other organizations such as unemployment, WIC, SSI, Disability, LifeHope Child Care Center, Non-profits, etc and would like to apply for assistance, please fill out the following form and email it to [email protected] to be submitted to our committee. 

• Reduced-Fee-Application

TREATMENT OF MINORS 

If you are bringing your 14-17 year old adolescent to counseling, please complete the Client Intake Form for Counseling and the Adolescent Informed Consent Form and bring them to your first counseling session. Both parent's signatures are required.

• Adolescent Informed Consent Form

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