Affinity Counseling

(432) 557-1775

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  • Counselors
  • Forms and Consents
  • Portal and Pricing
  • Online Counseling
  • Professional Referrals
  • Career Opportunities
  • Preschool Intervention
  • Pay My Bill
  • More
    • Home
    • Counselors
    • Forms and Consents
    • Portal and Pricing
    • Online Counseling
    • Professional Referrals
    • Career Opportunities
    • Preschool Intervention
    • Pay My Bill
Affinity Counseling

(432) 557-1775

  • Home
  • Counselors
  • Forms and Consents
  • Portal and Pricing
  • Online Counseling
  • Professional Referrals
  • Career Opportunities
  • Preschool Intervention
  • Pay My Bill

Forms and consents

Paperwork Made Easy

New client forms are the first step to starting your journey with your counselor. They are an essential tool to give you information about your rights and responsibilities regarding counseling and share with your counselor vital information to get to know you. 

We want to make this step as easy as possible. Below you will find an accessible e-sign version of each of our forms. Please complete all forms and consents that apply for each counseling participant. When you finish, we will input your paperwork into your chart. No scanning, faxing, or emailing is required.  However, if you prefer, a pen-on-paper PDF version is available for download at the very bottom for you to print and return. 


If you have any questions about your paperwork or which ones you need, please call Lindsey at 432-557-1775

New Client Forms

Adult intake

Adult intake

Adult intake

This form is required for individuals 18 years and older participating in individual counseling or couples counseling.

Complete Form

Child Intake

Adult intake

Adult intake

This form is required for children and adolescents participating in individual counseling or play therapy. Legal guardians must complete it. 

Complete form

Additional Forms

Release of Information

Release of Information

Release of Information

This form allows Affinity providers and staff to communicate with any listed individual.

Complete Form

Insurance update

Release of Information

Release of Information

Use this form to update, make changes, or add new or secondary insurance. 

Complete form

Express Payment

Release of Information

ONLINE COUNSELING CONSENT

Use this form to add a new credit, debit, or HSA card. 

Complete form

ONLINE COUNSELING CONSENT

Preschool Intervention Consent

ONLINE COUNSELING CONSENT

 This form is required for anyone participating in online counseling that completed new client paperwork before October of 2021

Complete form

Preschool Intervention Consent

Preschool Intervention Consent

Preschool Intervention Consent

 This form is required for families participating in our preschool intervention package.

Complete form

EMDR Consent

Preschool Intervention Consent

Preschool Intervention Consent

This informed consent provides additional information necessary for individuals being treated with EMDR. 

Complete form

patient Privacy Complaint Form

patient Privacy Complaint Form

patient Privacy Complaint Form

Complete form

Request for Acess To PHI Form

patient Privacy Complaint Form

patient Privacy Complaint Form

Complete form

Request for Acess To EHR Form

patient Privacy Complaint Form

Authorization for Use and Disclosure of Protected Health Information

Complete form

Authorization for Use and Disclosure of Protected Health Information

Authorization for Use and Disclosure of Protected Health Information

Authorization for Use and Disclosure of Protected Health Information

Complete form

Request for Amendment of PHI form

Authorization for Use and Disclosure of Protected Health Information

Request for Restriction of PHI form

Complete form

Request for Restriction of PHI form

Authorization for Use and Disclosure of Protected Health Information

Request for Restriction of PHI form

Complete form

Request for accounting of Disclosures for PHI Form

Learn more

Progress updates

Child Progress Update

Child Progress Update

Child Progress Update

This form is for guardians to complete at any time to help your child's counselor keep track of progress.

Complete Form

Teen Progress Update

Child Progress Update

Child Progress Update

This form is for teens and guardians to complete together to help your counselor keep track of progress. 

Complete form

School Note

School notes are only available upon request.

Please call or complete request to have one emailed to you. 

Request School Note

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Trámites simplificados

  

Los formularios para nuevos clientes son el primer paso para comenzar su viaje con su consejero. Son una herramienta importante para brindarle información sobre sus derechos y responsabilidades con respecto a la consejería, así como para brindarle a su consejero información importante para que lo conozca.

Queremos que este paso sea lo más fácil posible, a continuación, encontrará una versión accesible de firma electrónica de cada uno de nuestros formularios (en Ingles), favor de completar todos los formularios y consentimientos que se aplican a cada participante de la consejería. Cuando haya terminado, podremos ingresar su documentación en su gráfico sin necesidad de escanear, enviar por fax o por correo electrónico. Sin embargo, si prefiere un bolígrafo en papel, la versión en PDF está disponible para descargar en la parte inferior para que pueda imprimir y devolver. Favor de notar que los documentos para descargar están en Ingles, pero si pueden estar disponibles en español.  

Para recibir estos documentos en español, por favor mande un correo electrónico a Lindsey a info@affinitycounselingcenters.como si tiene alguna pregunta sobre su documentación o cuáles se aplican a usted y su familia, llame al 432-557-1775. 

Mas información

Downloadable PDF Versions

If you have issues with our e-sign forms or prefer to complete forms by hand, feel free to print forms here. 

You can return forms by emailing them to info@affinitycounselingcenters.com or faxing them to 432-897-0966.  If you would like to return them in person, please call ahead to ensure office staff is present. 

Adult Intake (pdf)Download
Child Intake Form (pdf)Download
Online Counseling Informed Consent (pdf)Download
Release Of Inforamtion (pdf)Download
Insurance Update Form (pdf)Download
Express payment consent (pdf)Download
Child Progress Update (pdf)Download
Teen Progress Update (pdf)Download
Preschool Intervention Consent (pdf)Download
Authorization (pdf)Download
Request for Access to EHR (pdf)Download
Request for Access to PHI (pdf)Download
Request for Accounting of Disclosures of PHI (pdf)Download
Request for Amendment of PHI (pdf)Download
Request for Restriction of PHI (pdf)Download
  • Professional Referrals
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Affinity Counseling

1030 Andrews Hwy Suite 108, Midland, TX 79701, US

(432) 557-1775

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