New Client Information Form

For your convenience, please complete and submit the New Client Registration Forms using our secure online process. Submitting this form online will allows us to prepare in advance for your visit and help us to provide the best care possible.

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Insurance

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I hereby authorize Affiliated Counseling Services to receive and release my information including (but not limited to) progress notes, treatment/discharge summary, psychological/neuropsychological assessment, healthcare records, educational records to the parties named above for continuity of care. I understand that this consent is reversable upon written request, except to the extent that action has been taken (e.g., information has already been released in accordance with this authorization).
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or until one year following date of signature. authorization).
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Medications

Health Conditions

Family members and all others in your home:

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