Cornerstone Counseling Center, PC

forms

Forms may be printed, completed and brought to your initial consultation. Forms are also available in the office for your use. Please allow 15 minutes prior to your initial appointment time to complete these forms. Click on the form you need. Please print and complete ALL 5 forms and bring them to your first session.

Find The Help You Need To Live The Life You Want

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†††††††††††† †††††††††††† Patient Data Form

†††††††††††† †††††††††††† †††††††††††† Obtains patient information.

 

 

†††††††††††† †††††††††††† Notice of Privacy Practices

†††††††††††† †††††††††††† †††††††††††† Informational sheet for the clientís use.

 

 

†††††††††††† †††††††††††† Consent of Treatment

†††††††††††† †††††††††††† †††††††††††† Provides consent to the therapist and Cornerstone Counseling Center to treat you.†

 

 

†††††††††††† †††††††††††† Authorization for Release of Information

†††††††††††††††††††††††††††††††††††† Provides consent to Cornerstone Counseling Center to release information to outside parties such as insurance

†††††††††††††††††††††††††††††††††††† companies, physicians or referral sources.†† † †††††††††††† ††††††††††††

†††††††††††††††††††††††††††††††††††† NO information about you or your treatment will be released without your consent.

†††††††††††††††††††††††††††††††††††† If the client is under 14 years of age, please have a parent or guardian sign.

 

 

†††††††††††† †††††††††††† Patient Contract

†††††††††††† †††††††††††† †††††††††††† Details many of Cornerstone Counseling Centerís policies about therapy.

 

 

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To contact us:

Phone: 717-671-9520

Fax: 717-671-9524