TEXAS COUNSELING AND WELLNESS CALL NOW (469) 499-4597

New Clients Forms
Please complete and print the following forms.
Please bring forms to our first meeting.*
1. Notice of Privacy Practices of HIPAA
2. HIPAA Acknowledgement of Receipt
3. Professional Disclosure Statement/Informed Consent
4. Adult Intake Form (adults only)
5. Adolescent Intake Form (adolescents only)
6. Credit card Authorization Form
Online Clients Only
Professional Disclosure Statement Online
*Services will be provided only after forms are received.
Please complete and print the following forms.
Please bring forms to our first meeting.*
Galit Ribakoff, M.S, LPC-S, NCC:
1. Notice of Privacy Practices of HIPAA
2. HIPAA Acknowledgement of Receipt
3. Professional Disclosure Statement/
Informed Consent
4. Adult Intake Form (adults only)
5. Adolescent Intake Form (adolescents only)
6. Credit card Authorization Form
Online Clients Only:
Professional Disclosure Statement Online
*Services will be provided only after forms are received.
- Welcome
- About Galit Ribakoff
- Services
- Rates/Packages and Payments
- New Clients Forms
- Remote Counseling/Telehealth
- Resources
- COVID-19 Anxiety/Boredom
- Sex and Intimacy
- Sexuality
- HRT
- Parenting
- Retreats
- Groups and Workshops
- Career Counseling
- Become an Entrepreneur
- Internship
- Publications
- Testimonials
- Contact Us
- Directions
- Disclaimer
- Welcome
- About Galit Ribakoff
- Services
- Rates/Packages and Payments
- New Clients Forms
- Remote Counseling/Telehealth
- Resources
- COVID-19 Anxiety/Boredom
- Sex and Intimacy
- Sexuality
- HRT
- Parenting
- Retreats
- Groups and Workshops
- Career Counseling
- Become an Entrepreneur
- Internship
- Publications
- Testimonials
- Contact Us
- Directions
- Disclaimer