Client Forms

For your convenience and to save time before your first appointment, we have provided the required forms that you will need to complete for your first appointment. By completing the documents before you arrive, you prevent the need to arrive early for paperwork.

Electronic Fill-in Forms
 

NOTE: The electronic-fill forms' 'Submit' buttons only work when the file is opened in Adobe Acrobat Reader, rather than opening it in your browser.

Open with Adobe Acrobat:

1. BEFORE completing a form, download/save the form files to your device (computer, phone, tablet):

    a. Right-click the desired form.
    b. Select 'Save link as', rename the file as form title, and then select where you want to save the file.

2. Open downloaded file in Adobe Acrobat:

    a. Locate the downloaded form file (using PC File Explorer OR MAC Finder).

    b. Right-click the form.

    c. Click 'Open with Adobe Acrobat Reader'.

    d. Fill in all appropriate fields.

    e. Click the 'Submit to Hoxworth Counseling' button to automatically email it to us.
Note: You should be prompted for the email program you want to use. If you are not prompted, you may have opened the file in your browser instead of sing Adobe Acrobat Reader; your file will NOT be sent when you click the 'Submit' button.

Note: We recommend that you also download/save the forms for your records, and so you can print in case we don't receive them via email.

Open file in Browser (without Adobe Acrobat Reader)

If you cannot use Adobe Acrobat Reader, you can still electronically complete the forms, and then bring them with you to your first appointment.
 

.   a. Click on the desired form; it will open in your browser.

    b. Fill in the appropriate form fields (do not click the Submit to Hoxworth button).
    c. Click the print button to print the form.
Note: We recommend that you also download/save the forms so you can easily make changes if necessary, and then re-print. 
   d. Sign the printed forms; bring them with you to your first appointment.

 

ADULT Client

electronic fill-in

1. Cover Letter

2. Consent for Services & Fee

3. Authorization for Scheduling, Billing and Payment Purposes

4. Cancellation Policy

5. PF1000 Notice of Privacy Practices

6. PF2000 Privacy Consent

7. Adult Intake form

8. Notification & Coordination with
      Primary Care Physician-Psychiatrist

 

LENS Neurofeedback forms:

Adult Consent form

Child/Adolescent Consent form

Intake form

CNS Questionnaire

Sensitivity Questionnaire

Photonic Stimulator Informed Consent form

MINOR (child/adolescent) Client
electronic fill-in

1. Cover Letter

2. Counseling Minors

3. Consent for Services & Fee

4. Authorization for Scheduling, Billing and Payment Purposes

5. Cancellation Policy

6. PF1000 Notice of Privacy Practices

7. PF2000 Privacy Consent

8. Child/Adolescent Intake Form

9. Notification & Coordination with
      Primary Care Physician-Psychiatrist

10. Notification & Coordination with Education Professionals
 

LENS Neurofeedback forms:

Minor Child/Adolescent Consent form

Intake form

CNS Questionnaire

Sensitivity Questionnaire

Photonic Stimulator Informed Consent form

Print and Manually fill-out forms
(Bring to your first appointment)

Download/save the form files to your device (computer, phone, tablet):

    a. Right-click the desired form
    b. Select 'Save link as', name the file, and then select where you want to save the file

    c. Locate the downloaded form files (using PC File Explorer OR MAC Finder)

    d. Double-click to open the file

    e. Print the form, and then manually fill out

    f. Bring the forms with you to your first appointment

ADULT Client

print & manually fill-out

Adult New Client Forms Packet - Print

Packet includes following individual forms:

1. Cover Letter

2. Consent for Services & Fee

3. Authorization for Scheduling, Billing and Payment Purposes

4. Cancellation Policy

5. PF1000 Notice of Privacy Practices

6. PF2000 Privacy Consent

7. Adult Intake form

8. Notification & Coordination with

      Primary Care Physician-Psychiatrist

LENS Neurofeedback forms:

Adult LENS Forms Packet - Print & manual fill in
Packet includes following 4 individual forms:

1. Adult Consent form

2. Intake form

3. CNS Questionnaire

4. Sensitivity Questionnaire

Photonic Stimulator Informed Consent form

MINOR (child/adolescent) Client

print & manually fill-out

Child/Adolescent New Client Forms Packet - Print

Packet includes following individual forms:

1. Cover Letter

2. Counseling Minors

3. Consent for Services & Fee

4. Authorization for Scheduling, Billing and Payment Purposes

5. Cancellation Policy

6. PF1000 Notice of Privacy Practices

7. PF2000 Privacy Consent

8. Child/Adolescent Intake Form

9. Notification & Coordination with
      Primary Care Physician-Psychiatrist

10. Notification & Coordination with Education Professionals

LENS Neurofeedback forms:

Minor Child/Adolescent LENS Forms Packet - Print & manual fill in
Packet includes following 4 individual forms:

1. Child/Adolescent Consent form

2. Intake form

3. CNS Questionnaire

4. Sensitivity Questionnaire

Photonic Stimulator Informed Consent form

4695 N M37 Hwy, Ste. A, Middleville, MI 49333

Phone: 269-205-2402

Fax: 269-205-2728

Email: info@hoxworthcounseling.com

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