Affinity Counseling

(432) 557-1775

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  • Forms and Consents
    • Home
    • Counselors
    • Portal and Pricing
    • Preschool Intervention
    • Online Counseling
    • Forms and Consents
Affinity Counseling

(432) 557-1775

  • Home
  • Counselors
  • Portal and Pricing
  • Preschool Intervention
  • Online Counseling
  • Forms and Consents

Forms and consents

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Paperwork Made Easy

New client forms are the first step to starting your journey with your counselor. They are an important tool to give you information about your rights and responsibilities in regard to counseling, as well as give your counselor important 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 are done- we will be able to input your paperwork into your chart no scanning, faxing, or emailing 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 apply to you and your family please call Lindsey at 432-557-1775

New Client Forms

Adult intake

Adult intake

Adult intake

For individuals 18 years and older participating in individual counseling or couples counseling.

Complete Form

Child Intake

Adult intake

Adult intake

For children and adolescents participating in individual counseling or play therapy, to be completed by legal guardians. 

Complete form

Consents

COVID-19 Guidlines

Somatic Experiencing Consent

Online counseling consent

Required for anyone participating in counseling at Affinity offices.

Complete consent

Online counseling consent

Somatic Experiencing Consent

Online counseling consent

Required for anyone participating in online counseling. 

Complete consent

Somatic Experiencing Consent

Somatic Experiencing Consent

Somatic Experiencing Consent

Required only for clients of Cameron Dumas.

Complete consent

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

Express Payment

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

Complete form

Downloadable PDF Versions

If you are having 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 make sure office staff is present. 

Adult Intake (pdf)Download
Child Intake Form (pdf)Download
COVID-19 Guidlines (pdf)Download
Online Counseling Informed Consent (pdf)Download
SE Consent- For Clients of Cameron Dumas (pdf)Download
Release Of Information (pdf)Download
Insurance Update Form (pdf)Download
Express payment consent (pdf)Download
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Affinity Counseling

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

(432) 557-1775

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