Forms

For new clients, the following noticed are required reading before proceeding to the online forms below. Estimated time to read through notices is 5-10 minutes. Please take a moment now to read these notices here:

• Informed Consent Form CA
• Informed Consent Form TN

• Telehealth Disclosure
• HIPAA Notice

AFTER reading the above notices, you will need to fill out 2 online forms:

Client Intake Questionnaire and Symptoms List

Each online form must be filled out in one sitting and you cannot save information entered.

Estimated time to fill out the Client Intake Questionnaire is between 30-40 minutes so plan accordingly. Estimated time to fill out the Symptoms List is 10 minutes.

You can access these forms here:

Client Intake Questionaire
https://hushforms.com/listercounseling-client-intake-questionnaire

Symptoms Checklist
https://hushforms.com/listercounseling-symptoms-list

Optional one-page form to be filled out only if directed to do so:

• Release of Information

FOR CASH PAYING CLIENTS ONLY

GOOD FAITH ESTIMATE