If you're a new client, please complete the following forms and bring them to your first therapy session. Adult clients need to only complete the Adult Intake Form - New Patients. Minor children and families need to complete both the Child Intake Questionaire and the Parent Intake Forms.
If you're an existing client, please go to the bottom of this page to review the instructions for the 2021 Adult Update form.
|Child Intake Questionaire - New Patients|
|Parent Intake Form - New Patient|
If you are a new client, and would like to utilize our new TeleHealth options, please complete the Adult Intake Form for TeleHealth (below).
Instructions for use of the TeleHealth form:
- Click on the link, this will open the form in your browser.
- Fill out the form - be sure to type your name and check the agreement box for each signature line (there will be 5 signature lines to fill out)
- When completed you should save the file on your computer for your records / future reference.
You will then need to do one of the following in order to get the document to us (NOTE: These forms must be received by our Office prior to your appointment, or we will have to reschedule):
- Print and then FAX this form to (352)365-6596 NOTE: If you don't have a FAX machine at home there are many local options for sending FAXes in your local community. Check your office supply store (Office Depot), print shops (Kinkos), or shipping stores.
- Print, place in a sealed envelope, and then drop off this form at our office: 1514 W Main St, Leesburg FL 34748.
NOTE There is a mail slot in the front door (facing Main St) that can be used after hours, or in the event that you would like to avoid any personal contact during this time.
- Print and mail this form to our office: 1514 W Main St., Leesburg FL 34748. Please allow sufficient time for the document to arrive.
- E-Mail the document/file as an attachment using your normal email to our internal email: [email protected] NOTE: If you choose to E-Mail this document please be aware that as email uses a public service for delivery any such email will not comply with HIPAA or PHI requirements. As a result, please be aware that there is some risk that your email may not be private. You can encrypt your file prior to sending it for some additional protection using a ZIP utility. If you would like to discuss this option, please call our IT Support staff at (352)775-2735. If there is not answer, please leave a message and someone will contact you within 24 hours.
If you are an existing client and have scheduled sessions in 2021 you must submit a completed and signed Adult Update Form before your next appointment. You can review the instructions for completing and returning this form below. Once you have reviewed the instructions, you can then download the form by clicking on the link below.
Note: To download Adobe Acrobat Reader for free, click here.