New Client Intake Forms

INSTRUCTIONS:

• The below forms are REQUIRED.

• If you have a minor who will be receiving counseling, the Consent form must ALSO be filled out.

• Forms must be completed for EACH person. One form each per client.

• Click on each individual link to view, complete the forms and return at least 24 hours prior to your session.

• Failure to send in forms 24 hours prior to your session may cut into your session time as you will be required to fill out all forms in person at the time of your appointment. We look forward to seeing you soon!

Services Agreement- (Sign & return)

Enrollment Form- (Fill out, sign & return)

Consent to Audio/Video Record (Sign & return)

Consent for Children (Sign & return for MINORS ONLY)

Cancellation Policy:

All cancellations result in a $50.00 fee regardless of the reason. Because we must still pay employees and the counselor must still be present during the time of each appointment, the cancellation fee is firm regardless of the reason. Clients may reschedule twice with no fee as long as they do so within 3 days of their appointment.

Office Number: (501) 238- 3600

Fax Number: (501) 683-8404

Email Address: counseling@drniokasmith.com