Vicki Ray, MBA, MA, LPC

Professional Counseling Services

Forms for New Clients

If you are a new client, please print and fill out these forms to bring with you for your first appointment.  This will allow us to spend more time talking and less time on paperwork the first time we meet.

For Adult Clients:

Informed Consent Form - please print and sign TWO copies of this form (you keep one copy and I keep one copy)

Client Information Form

HIPPA Compliance

Insurance Information Form - please fill this out only if you plan to use insurance

For Adolescent Clients:

Informed Consent Form - to be signed by the adolescent client and the parent(s)/guardian(s).  Please print and sign TWO copies of this form (you keep one copy and I keep one copy)

Agreement with Minor - to be signed by the adolescent client and the parent(s)/guardian(s).  Please print and sign TWO copies of this form (you keep one copy and I keep one copy)

Client Information Form - this asks for history about the adolescent client.  The adolescent and parent(s)/guardian(s) may want to work on this together.

HIPPA Compliance

Consent for Treatment of Minors - to be filled out by the parent(s) or guardian(s)

Insurance Information Form - please fill this out only if you plan to use insurance