If you would like the opportunity to read and fill out forms prior to your first appointment, please select which heading applies to you, and fill out the forms listed. If you have Medicaid as your insurance, please also complete the forms under that heading. Otherwise, please arrive about 15-20 minutes early and we will give you the forms upon your arrival to our office and ask you to complete them in our waiting room. We do understand it's a lot of paperwork, but it's become necessary in the current insurance and HIPPA environment.

 

Telehealth Consent Form: If you are using telehealth for counseling during the Covid-19 Pandemic please click the link below and download and sign the Telehealth Consent Form

Telehealth Consent Form

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ADULT FORMS (non-Medicaid)

Please click the link below, download and complete all forms

Client Intake Forms - Adult

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CHILD/ADOLESCENT FORMS (non-Medicaid)

Please click the link below, download and complete all forms

Client Intake Forms - Child/Adolescent
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MEDICAID CLIENT FORMS

Please click the links below, download and complete all forms, 

choosing Adult or Child/Adolescent as appropriate then Self Assessment

Client Medicaid Intake Forms - Adult

Client Medicaid Intake forms - Child/Adolescent

Self Assessment

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JOHN L HOLT, LCMHC

If you are seeing John please download this form as well

LCMHC professional disclosure statement

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DEBI PRUITT, LCMHCA

If you are seeing Debi please download these forms as well

LCMHCA professional disclosure statement

Recording consent form