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

5. ONLY NEEDED FOR TELEHEALTH CLIENTS: Individual Plan of Care Consent Form

6. ONLY NEEDED IF YOU WANT RECORDS RELEASED: Authorization to Release Info Form

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

Client Demographic Info 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. Copay Credit Card Authorization Form (NOT NEEDED FOR MEDICAID CLIENTS)

5. ONLY NEEDED FOR TELEHEALTH CLIENTS: Individual Plan of Care Consent Form

6. ONLY NEEDED IF YOU WANT RECORDS RELEASED: Authorization to Release Form

CONTACT US FOR MORE INFO OR TO SCHEDULE AN APPOINTMENT