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

Additional Forms

Release of Information

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

Complete Form

Insurance update

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

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

Complete form

EMDR Consent

Preschool Intervention Consent

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

Complete form

patient Privacy Complaint Form

Complete form

Request for Acess To PHI 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

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

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

Forms and consents

Paperwork Made Easy

New Client Forms

Adult intake

Adult intake

Adult intake

Child Intake

Adult intake

Adult intake

Additional Forms

Release of Information

Release of Information

Release of Information

Insurance update

Release of Information

Release of Information

Express Payment

Release of Information

ONLINE COUNSELING CONSENT

ONLINE COUNSELING CONSENT

Preschool Intervention Consent

ONLINE COUNSELING CONSENT

Preschool Intervention Consent

Preschool Intervention Consent

Preschool Intervention Consent

EMDR Consent

Preschool Intervention Consent

Preschool Intervention Consent

patient Privacy Complaint Form

patient Privacy Complaint Form

patient Privacy Complaint Form

Request for Acess To PHI Form

patient Privacy Complaint Form

patient Privacy Complaint Form

Request for Acess To EHR Form

patient Privacy Complaint 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

Authorization for Use and Disclosure of Protected Health Information

Request for Amendment of PHI form

Authorization for Use and Disclosure of Protected Health Information

Request for Restriction of PHI form

Request for Restriction of PHI form

Authorization for Use and Disclosure of Protected Health Information

Request for Restriction of PHI form

Request for accounting of Disclosures for PHI Form

Progress updates

Child Progress Update

Child Progress Update

Child Progress Update

Teen Progress Update

Child Progress Update

Child Progress Update

School Note

School notes are only available upon request.

Request School Note

Trámites simplificados

Downloadable PDF Versions