If you're a first-time client, you will need to print and complete the New Client Forms. These six (6) forms may be downloaded from the links near the bottom of this page.  Please bring the completed forms, along with your insurance card, to your initial session.  NOTE: If you are divorced from your child's other parent; please provide a copy of the Divorce decree and/or a copy of the Custody agreement so that assurance of all appropriate consents are available at the initiation of the counseling relationship.   

ADDITIONAL NOTE: If you have either United Healthcare or TriCare insurance coverage there is additonal  information for you to complete.  You will find the specific forms marked by an asterisk (*) below.  

New Client Forms (Links below)

• New Client Information
  
• Informed Consent
  
• Rights and Responsibilities
• HFCA (You only need to sign & date Box 12 and Box 13)
• Fee Schedule
• PCP Release 

*United Healthcare/United Behavioral Wellness Form

• Adult
  
• Child/Adolescent

*Tricare Letter of Referral Form

• TRICARE Letter of Referral - TRICARE requires preauthorization and a referral from your physician.  (1). You may obtain the preauthorization number by contacting the mental health/behavioral health department for TRICARE.  (2). The letter of referral may be given to your physician to complete and then faxed to (770) 993-9800 or brought to the first appointment.  
  

Optional Forms

• Release of Information - This form is to be completed if you are requesting that I communicate (via phone, fax, email, etc...) with someone (without your presence) including family members, spouse, partner, friends, or other professionals.
• Privacy Notice - This form is the "medical records privacy law" (i.e. HIPAA).  You may print a copy for your records and/or request a copy at your initial visit.
• Sliding Fee Scale - For clients who either do not have insurance coverage or want to self-pay.

New Client Information
Informed Consent
Rights & Responsibilities
HFCA	(You are only need to sign & date Box 12 and sign Box 13)
Fee Schedule
Adult Wellness	(For United Behavioral Healthcare Adult clients ONLY)
Child/Adolescent Wellness	(For United Behavioral Healthcare Child/Adolescent clients ONLY)
Release of Information	Please complete this form if you are requesting that I communicate (via phone, email, etc...) with someone (without your presence) including family members, spouse, partner, friends, or other professionals.
Privacy Notice	This form is the "medical records privacy law" (i.e. HIPAA). You may print a copy for your records and/or request a copy at your initial visit.
PCP Release
TRICARE Letter of Referral	(For TRICARE members ONLY)
Sliding Fee Scale

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