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Counseling and Psychotherapy

New Client Forms  

Dear New Client,  

I am looking forward to meeting with you.  I am very hopeful that we will be effective in working toward your goals.  

To get us started in this process,  please download the appropriate set of forms (please scroll down to see the links to these forms) and complete them prior to your first visit. Please bring all the completed paperwork with you when you come for your appointment.  We will use this information, and other elements, to help us define and explore the issues you want to resolve.  Completing the paperwork ahead of time allows us to use our time together more effectively.  

If you have any questions or concerns, please do not hesitate to call me. 

Joanne (Jodi) M. Moore, LPC, NCC, BCETS, CCH    

Instructions:  Click on the appropriate link (below) to download a form.  When prompted by an on- screen dialogue box, click "save" to save the document to your computer.  Then, choose the "open" option in the next on-screen dialogue box.  Print the document and maintain the saved copy for your records.

ALL ADULT CLIENTS, please download and complete: (1) New Client Form (adult version),   (2) Professional Disclosure Statement,  (3) Directions to the Practice, (4) Physician Oversight Notice (Tricare Clients only), and the (5) Release of Information Form (Tricare Clients only).

PARENTS/GUARDIANS OF CHILD AND ADOLESCENT CLIENTS, please download and complete: (1) New Client Form (child or adolescent version, as appropriate), (2) Professional Disclosure Statement,  (3) Directions to the Practice, (4) Physician Oversight Notice (Tricare Clients only), (5) Release of Information Form (Tricare Clients only), and (6) Permission to Treat a Minor Child/Adolescent, 

Note: Please print the New Client Form that is appropriate to the age level of the client.  If two or more people are seeking counseling together,  please print one New Client Form packet for each individual.

NEW CLIENT DOCUMENTS (click on the links below):

New Client Form (Adult Version) 

New Client Form (Adolescent Version)

New Client Form (Child Version)

Professional Disclosure Statement

Permission to Treat a Minor Child/Adolescent (To be signed by the parent or legal guardian of any client under the age of 18).

Directions to Office

ADDITIONAL DOCUMENTS COMPLETED BY TRICARE CLIENTS ONLY

TRICARE Medical Referral Form  (This form is required for all TRICARE clients.  Simply have your physician or nurse practitioner sign it before your first session and bring it in with you when you come).

Release of Information Form (This form is required by Tricare, and allows Stillwaters Counseling to file an insurance claim with Tricare for coverage of services).

For more information or to schedule an appointment, please call (757) 404-3747 or email Jmoore@stillwaterscounseling.com