New Clients Forms

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TEXAS COUNSELING AND WELLNESS, PLLC

CALL NOW (469) 499-4597

New Clients Forms

Please complete the following forms.*

Please email the forms to gribakoff@gmail.com before the initial meeting.

1. Notice of Privacy Practices of HIPAA

2. HIPAA Acknowledgement of Receipt

3. Professional Disclosure Statement/Informed Consent

4. Adult Intake Form (adults only)

5. Adolescent Intake Form (adolescents only)

6. Credit card Authorization Form

*Services will be provided only after forms were received.

*Please use a PDF program to fill these forms.

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