Client Intake Paperwork
For New Clients, Please fill out these forms at least ONE day before your appointment.
Disclosure Notice to SIGN
Online Therapy Agreement
All New Online Clients must FILL OUT/SIGN
ELECTRONICALLY the top THREE forms in Orange at least ONE DAY BEFORE your appointment (In office clients can sign the top two forms ahead or time or in the office.) You will be able to save copies of these documents for your records.
Each button will walk you through the process. Thank you.
For Couples, each person will have to fill out their own forms separately.
For Online Therapy Clients: We are required by law to verify your identity. Please email a copy of a picture ID that has your name on it. (you can simply take a legible photo of your ID and email it to us.) You may black out any information except Name, Address, and Date of Birth off of the ID if you want. We do not keep hard copies of your ID. If you want to send the copy through an encrypted email server from your end, please create a free account with Send Inc to forward any information to our encrypted email. (firstname.lastname@example.org)
Once you have completed the forms online, the paperwork is automatically sent to our office. You are ready for your appointment. Thank you!
Credit Card Authorization Form (Only Required when Be Replenished Counseling Manually Enters Payment. Normal Payments are taken through our Client Appointment Scheduler and you enter payment information.)
NO HARM CONTRACT
RELEASE OF INFORMATION AUTHORIZATION