FORMS

 

The following forms help me to both get to know you and the challenge that resulted in you considering counseling, but they also represent ways in which we will be working together and the information you need to know in regards to confidentiality, etc. that is important for you to understand. Please print and complete the documents, and bring them with you to your first appointment. This will greatly reduce time and allow us to move forward more quickly (Document 04 is the only one that you do not have to bring to your appointment). 

01

Intake Form

 

The intake form is the way in which I get to know a little more about you, your life in context or connection with your family, community, place of worship, etc.  It is also a place where you may help me to better understand the challenges that bring you to consider seeking assistance at this particular point in time.

02

Participation Agreement

 

The Participation Agreement represents your consent to move forward with our work together. It also represents the commitments that we make to one another as we begin this exciting venture. 

03

Release of Information

 

In certain instances, providing you with the best care may mean consulting with your Primary Care Physician or other health care professional. In the event that this becomes necessary, it is important to have a release of information on file. Please print, sign and bring this document to your first session.

04

Notification of Privacy

 

The notification of privacy outlines the ways in which your Protected Health Information (PHI) may be used in order to carry out our work, payment and for other purposes. This disclosure outlines your rights to information and confidentiality, and discloses all of the ways that Destin Counseling Services may use this information. It is important that you read the document, and maintain a copy for your records.

3209 W Smith Valley Rd  Suite 224

Greenwood IN 46142

Phone:  (317) 884-5012

FAX:       (317) 884-5011

 

                         Office Hours

Tue - Fri               12:00 pm - 9:00 pm

Sat                         9:00 am - 3:00 pm

Email Us:

jt@destinservices.com

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