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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.

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