TEXAS COUNSELING AND WELLNESS, PLLC
CALL NOW (469) 499-4597
New Clients Forms
Please complete and print the following forms.
Please bring forms to our first 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
Online Clients Only
Professional Disclosure Statement Online
*Services will be provided only after forms are received.
Please complete and print the following forms.
Please bring forms to our first meeting.*
Galit Ribakoff, M.S, LPC-S, NCC:
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
Online Clients Only:
Professional Disclosure Statement Online
*Services will be provided only after forms are received.