Coastal Haven Counseling Forms

New Client Forms:

Adult Intake Forms

1. Group Professional Disclosure Statement Form

2. Adult Initial Clinical Assessment Form

3. Assessment Tool (Cross Cutter) for Adult Client

4. Authorization to Release Form

5. Copay Credit Card Authorization Form (NOT NEEDED FOR MEDICAID CLIENTS)

Couples Counseling Questionnaire

Also fill out adult forms to the left.

Couples Intake Questionnaire Form

Additional Forms:

Authorization To Release Form

CHC Privacy Practices Info

FOR DOCTOR OFFICE REFERRALS: Fax In This Referral Form

TeleHealth / TeleTherapy Informed Consent Form

Interpreter Services

Self Pay Clients Good Faith Estimate of Costs

Child Client Intake Forms

1. Group Professional Disclosure Statement Form

2. Child Initial Clinical Assessment Form

3. Assessment Tool For Child (Cross Cutter) Age 6-17

4. Authorization to Release

5. Copay Credit Card Authorization Form (NOT NEEDED FOR MEDICAID CLIENTS)

CONTACT US FOR MORE INFO OR TO SCHEDULE AN APPOINTMENT