My Services
(Formerly Hoxworth Counseling Services)
For appointment, call 269-205-2402
Electronic Fill-In 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.
Directions
1. Click on the desired form; it will open in your browser.
2. Fill in the appropriate form fields.
3. Click the print button to print the form.
Note: We recommend that you download/save the forms so you can easily make changes, and then re-print them.
4. Sign the printed forms; bring them with you to your first appointment.
ADULT Client
electronic fill-in
1. Cover Letter
3. Authorization for Scheduling, Billing and Payment Purposes
5. PF1000 Notice of Privacy Practices
8. Notification & Coordination with
Primary Care Physician-Psychiatrist
9. Emergency Contact Authorization
10. Consent for Self-Pay Fee Sessions
Adult LENS Neurofeedback forms
MINOR (child/adolescent) Client
electronic fill-in
1. Cover Letter
4. Authorization for Scheduling, Billing and Payment Purposes
6. PF1000 Notice of Privacy Practices
8. Child/Adolescent Intake Form
9. Notification & Coordination with
Primary Care Physician-Psychiatrist
10. Notification & Coordination with Education Professionals
11. Emergency Contact Authorization
Minor LENS Neurofeedback forms