David's Forms

If you're a first-time client, you will need to print and complete the New Client Forms . Please select and complete the forms for the location you are scheduled (Marietta or McCaysville). These forms may be downloaded and completed from the links below.  

Please 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.

Under Section 2799B-6 of the Public Health Service Act (Good Faith Estimate for Health Care Items and Services) individuals who are either uninsured (not enrolled in a plan or coverage or a Federal health care program) or self-pay (individuals who are enrolled in a plan or coverage or a Federal health care program but not seeking to file a claim with their plan or coverage) can request and be provided (orally and in writing) a good faith estimate of expected charges for items and services.

If a service is scheduled at least 10 business days in advance the Good Faith Estimate will be provided within 3 business days of scheduling. If a service is scheduled at least 3 business days in advance the Good Faith Estimate must be provided within 1 business day of scheduling. If a service is scheduled less than 3 business days in advance a Good Faith Estimate is not required. If an individual requests a Good Faith Estimate it must be provided within 3 business days.

NOTE : If you have United Healthcare/United Behavioral insurance there is an additional form for you to complete (listed under Other Miscellaneous Forms).

David's Forms - Marietta Office 

David's Forms - McCaysville Office   

David's NEW CLIENT Forms - MARIETTA OFFICE   

NOTE: All 7 documents must be completed and received by the office via email at [email protected] or fax at  770-993-9800 at least twelve (12) hours before your scheduled appointment as confirmation of your intent to attend.

  1. New Client Information ( PDF fill-in form )
  2. Informed Consent
  3. Rights and Responsibilities
  4. HCFA (You only need to sign & date box 12 & sign box 13)
  5. Healthcare Professional Release
  6. Fee Schedule
  7. If using Insurance please include a copy of your insurance card.  If using an EAP please provide the EAP company name, number and authorization number.  

Other Miscellaneous Forms

  • United Healthcare/United Behavioral Wellness Form - This form is to be completed if you have UHC/UBH insurance.
  • Adults (18 and up)
  • Minors (under 18)
  • Consent / 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, or other professionals.
  • Adults (18 and up)
  • Minors (under 18)
  • 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.

David's NEW CLIENT Forms - McCAYSVILLE OFFICE  

NOTE: All 7  documents must be completed and received by the office via email at [email protected] or fax at 770-993-9800 at least twelve (12) hours before your scheduled appointment as confirmation of your intent to attend.   

  1. New Client Information ( PDF fill-in form )
  2. Informed Consent
  3. Rights and Responsibilities
  4. HCFA (You only need to sign & date box 12 & sign box 13)
  5. Healthcare Professional Release
  6. Fee Schedule
  7. If using Insurance please include a copy of your insurance card.  If using an EAP please provide the EAP company name, number and authorization number.  

Other Miscellaneous Forms

  • United Healthcare/United Behavioral Wellness Form - This form is to be completed if you have UHC/UBH insurance.
  • Adults (18 and up)
  • Minors (under 18)
  • Consent / 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, or other professionals.
  • Adults (18 and up)
  • Minors (under 18)
  • 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.


NOTE : If you need any programs to view the forms, they are free to download at the following links:

New Client Information (Word Doc Form)
New Client Information (Fillable PDF Form)
Informed Consent
Rights & Responsibilities
HCFA (You only need to sign & date Box 12 & sign Box 13)
Fee Schedule
Privacy Notice This form is the "medical records privacy law" (HIPAA). You may print a copy and/or request a copy at your initial visit.
Healthcare Professional Release Please provide any information regarding current or prior medical and/or mental health treatments.
Sliding Fee Scale (Marietta)

Sliding Fee Scale (Marietta Office)

Sliding Fee Scale (McCaysville) Sliding Fee Scale (McCaysville Office)

Helpful Forms

Click here to view and print forms for your appointment.

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