Client Forms

Click on the links below to print, review, and complete the following forms to bring to your first appointment.

Please feel free to ask any questions you may have prior to signing!

Registration Form

This form covers your basic contact information.

Informed Consent

This form provides detailed information about the counseling process, payment options, and more. It also serves as a consent for me to treat you.

HIPAA

This form discusses patient privacy.


The following forms are OPTIONAL. You only need to complete them if requested.

Release of Information

This form authorizes the release of protected health information to a designated party.

Third-Party Payment Authorization

This form must be filled out and signed only if someone other than the identified client will be paying for the counseling sessions.

Release of Information (Billing Only)

This form serves to protect a client’s protected health information from being released when a third-party is paying for the counseling sessions.

What’s My M3?

This website (also available in an app format!) will quickly screen you for certain mental health symptoms. Feel free to print the results and bring to your first appointment, or email them to me at bethaney@swflcounsel.com.



bethaney@swflcounsel.com
941-258-6944

Send a Message