Client Forms

Here you will find all of the forms you need to get started as a client of Christian Life Counseling, LLC. All forms are sorted by category for your convenience. The categories are: Adult Forms Packet (blue section), Child Forms Packet (green section), Review Only Forms (yellow section), Release Forms (grey).

Click on the .PDF image icon to download the form you need. The form will open in a new browser window. Please print the forms, complete the forms, and bring them with you to your appointment. If you have questions, please call the office at 262-785-1008.




 

Adult Forms Packet (Please right click on link & open in new window)

If you are 18 years of age or older and are a legal adult in the US, please fill out the forms here in the blue section. Additionally, please read through the forms in the yellow section (you only have to read and review the yellow section forms, you do not have to print and sign the yellow section forms).
Adult Intake Form (part of intake packet) HIPAA Sheet Forms Checklist

file name:
2017.1-clc-adultintake.pdf

file name:
2017-clc-hipaasheet.pdf


file name:
2017-clc-
newclientpapeworkchecklist.pdf
Authorization for Release of Confidential Information to my Primary Care Physician (PCP Form 2) Client Acknowledgment and Authorization Form Fee Schedule

file name:
2017.1-clc-pcpwaiver.pdf

file name:
2017-clc-clientacknowledgementauthorization.pdf




 

Child Forms Packet (Please right click on link & open in new window)

If you are under the age of 18, and are not a legal adult in the US, or, if you are a parent/guardian that is completing forms for a minor patient, please fill out the forms here in the green section. Additionally, please read through the forms in the yellow section (you only have to read and review the yellow section forms, you do not have to print and sign the yellow section forms).
Child Intake Form (part of intake packet) HIPAA Sheet Forms Checklist

file name:
2017-clc-childintakeform.pdf

file name:
2017-clc-hipaasheet.pdf

file name:
2017-clc-
newclientpaperworkchecklist.pdf
Authorization for Release of Confidential Information to my Primary Care Physician (PCP Form 2) Client Acknowledgment and Authorization Form (Please have children 14 and older sign) Fee Schedule

file name:
2017-clc-pcpwaiver.pdf

file name:
2017-clc-clientacknowledgementauthorization.pdf





 

Review Only Forms

Here in the yellow section are the forms that you need to read and review, but do not have to print and sign. If you are an adult, please make sure to fill out all of the forms in the blue section. If you are under the age of 18, and are not a legal adult in the US, or, if you are a parent/guardian that is completing forms for a minor patient, please fill out the forms in the green section.
Review: Consent to Treatment Review: State of Wisconsin RIGHTS OF CHILDREN AND ADOLESCENTS In Outpatient Mental Health Treatmen Review: Client Rights and the Grievance Procedure for Community Services
Click to Download
file name:
2013-clc-consenttotreatment.pdf
Click to Download
file name:
2013-clc-stateofwisconsinrightsofchildrenadolescents.pdf
Click to Download
file name:
2013-clc-clientrightsgrievences.pdf
Review: Privacy Practice Notice    
Click to Download
file name:
2013-clcprivacypracticenotice.pdf
   




Release Forms

Here in the grey section are the release forms. You will need to access these forms for various reason throughout the course of your treatment, as well as after treatment has ended.
Authorization for The Disclosure Of Protected Health Information
Click to Download
file name:
2013-clc-
authorizatioddisclosurehealthinfo.pdf