PLEASE Print out the paperwork on single side paper. Please bring all the paperwork with you to your appointment. Please read over the paperwork carefully and answer all the items or questions asked. If you have any questions about the paperwork or policies, please mark them, and we can discuss them at your first appointment.
We understand that this paperwork packet may be lengthy and time-consuming, so please take your time in going through each section at your own pace and feel free to take breaks. Having this packet completed before your intake session will help your counselor in your therapeutic process. We appreciate your completion of this task.
Please make sure to print and fill out the correct paperwork packet by finding the packet by the title shown below. If you are unsure which packet you should print and fill out, please call our office at 662-338-1880
NEW CLIENT PAPERWORK
ADULT Paperwork -- This paperwork must be completed by the client. *If there is more than one individual being provided services, this paperwork will have to be completed for each individual separately. Example; couples or family counseling.
CHILDREN / MINOR Paperwork -- This paperwork must be completed by the parent or guardian of the child. *If there is more than one child being provided services, this paperwork will have to be completed for each minor separately.
ADHD Assessment for ADULT Clients – This will need to be completed by the client.
Alcohol and Drug Assessment for ADULT Clients -- This will need to be completed by the client. *There is an additional form that will have to be completed in the office.
Authorization to Release Confidential Information Form – This form may be required for doctors, past therapists, teachers, family members, attorneys or legal aids, or other individuals who you, the client, give written permission to release information for the purpose of making payments on your account, discussing treatment plans and goals, and therapeutic process.
Custody Consent Form – This form may be required if parents or guardians are separated or divorced and have joint custody legal rights over the child/minor. A copy of the legal custody document(s) will be needed upon intake. If you have questions in regard to this form, please contact the Office Administrator.
Credit Card on File Authorization Form – If you would like to put a credit card on file, we will need you to complete the authorization form and sign the agreement. If you have questions in regard to this form, please contact the Office Administrator.
Telehealth Agreement – If you would like to receive services via telehealth in any platform we provide (website, Zoom, Facetime, Skype, etc.), you must complete the agreement form. You must mail the original back to us at PO BOX 1452, Starkville, MS 39760. You may send us a signed copy via email, fax, or text until the original is received by our office so as not to pause your services.