Download Forms

It would be helpful to have all forms filled out before your actual appointment. There are several options to accomplish this:

  1. You can come 30 minutes before your appointment to fill it out in the waiting room.
  2. You can pick them up at our offices in advance of your appointment during normal working hours and fill them out at your leisure.
  3. You can download them from this page to your computer. You have the option of:
    • Download Microsoft Word files, fill them out on-screen, then print them out and and bring them to your appointment.
    • Download Adobe PDF files, print them out, fill them out by hand and bring them to your appointment.

To view the forms, click on the name of the desired form. The form will either be downloaded to your computer or it will display in a separate window depending upon file type, browser used, etc.

All Clients
Form Description .doc .pdf
Contract, Office Procedures, and Financial Agreement for Psychotherapy Services

Intake Form

Notice of Privacy Practices (HIPPA Disclosure)		 These forms provide critical information about our office policies, procedures, and consents. Your signature indicates agreement and compliance. If you do not sign these forms, we cannot treat you. Everyone must sign and date. If you have any questions, you may raise them with the therapist at your first session. Word PDF
Adults
Form Description .doc .pdf
Adult Questionnaire Adults provide this form to the therapist at the time of service. Collects information about your past history and current situation and it is very helpful and will save the therapist a lot of time, reserving the therapy session for discussion and conversation about the presenting problem and your needs. If seeking couples or marital counseling, both need to fill out this form. Word PDF
Minors
Form Description .doc .pdf
Adolescent Questionnaire Teens complete this inventory to bring to their first individual counseling appointment with the therapist. Word PDF
Child Questionnaire This form is completed if the child is the identified client. Parents/legal guardians complete the form on the child’s behavior, desired changes, problem areas, etc. Please bring this information to your first appointment with the therapist. Word PDF
Consent for Counseling Services To Child(ren) In order for minor children (18 years of age & under) to receive psychological services, it is necessary for the parent or legal guardian to grant permission for such services to occur. Word PDF
Minors Psychotherapy Agreement Youth 18 years and under consent for counseling and psycho-educational services. Parents or legal guardians must also sign and date. Word PDF
Groups, Classes & Workshops
Form Description .doc .pdf
Registration Form for Teen Classes and Groups Teen registration form for classes/groups. Word PDF
Supplemental
Form Description .doc .pdf
Authorization for Release of Confidential Information For sharing records and/or treatment goals and outcomes between counselors, lawyers, pastors, teachers, non-custodial parent, etc. Word PDF
Court Services Agreement (Licensed Therapist) For clients who may be involved in a court case or related consultation with a licensed therapist. Word PDF
Court Services Agreement (Pre-Licensed Therapist) For clients who may be involved in a court case or related consultation with a pre-licensed therapist. Word PDF
Drug Testing Consent Form For clients authorizing Olive Branch Counseling Centers to perform a drug test. Word PDF
HMO Insurance Worksheet This insurance verification form is for your assistance to help you find out about your insurance coverage. There are suggested questions that you could ask and helpful things that you need to know when dealing with your HMO. Word PDF
Olive Branch Counseling Center Evaluation Please take a few minutes to provide us with feedback for our annual evaluation to let us know how well we are doing. Submit anonymously. Thank you. Word PDF
Sliding Fee Scale Application This form provides us with proof of income. Please bring to your first session. Word PDF