Printable Forms For Therapists

New Client Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

Please fill out the following form:
https://docs.google.com/forms/d/e/1FAIpQLSe5nuiPftCwtD1utZ3YcvCj0X_--rxVFRmpSfjVGNzUQPzFBw/viewform?usp=sf_link

NEW PATIENT FORM - Personal Data Questionnaire
Please fill out all questions before we get started

* Indicates required field

Full Name and Phone Number *

Address *

Email Address *

Emergency Contact *

Date of birth *

Are you Married, Single, Divorced, Other? *

How many kids? *

Who lives with you in your home? *

Where do you work? *

List all prescribed medication *

List all OTC (over the counter) medication including vitamins and supplements? *

Any medical concerns now? *

Any known allergies? *

Overall Health Condition? *

Any special request? *

Which program are you enrolling? (Detox, Counseling, Supplements Advisory, Nutrition...) Which difficulties you think you can find to fulfill this program? *

Being specific, how do you expect to be helped? *

How did you hear about us? *

Submit

hlcc_adult_intake_form-new_client__1_.pdf
File Size:	274 kb
File Type:	pdf

Download File

hlcc_account_information.pdf
File Size:	49 kb
File Type:	pdf

Download File

hlcc_child_intake.pdf
File Size:	149 kb
File Type:	pdf

Download File

hlcc_client_agreement_and_therapeutic_policies.pdf
File Size:	167 kb
File Type:	pdf

Download File

hlcc_consent_for_treatment_of_a_minor_child.pdf
File Size:	139 kb
File Type:	pdf

Download File

Client Intake Form
File Size:	75 kb
File Type:	pdf

Download File

Limits of Confidentiality/Cancellations
File Size:	71 kb
File Type:	pdf

Download File

Current Client Forms

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

Authorization to Disclose
File Size:	2382 kb
File Type:	pdf

Download File

Note: To download Adobe Acrobat Reader for free, click here.

High Level
Health & Wellness Center
6399 W Colonial Dr,
Orlando, FL 32818

Phone: (407) 668-6025
verbeniasousa@yahoo.com

Printable Forms

New Client Forms

NEW PATIENT FORM - Personal Data Questionnaire
Please fill out all questions before we get started

Current Client Forms

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Contact Us

Printable Forms

New Client Forms

NEW PATIENT FORM - Personal Data QuestionnairePlease fill out all questions before we get started

Current Client Forms

Navigation

Connect

Contact Us

NEW PATIENT FORM - Personal Data Questionnaire
Please fill out all questions before we get started