Forms & Referrals

New Client Forms:

Click here for the Telemental Health Consent Form. After reading this form, please fill out and submit the form below to give consent electronically.

Name

First Name

Last Name

If client is 17 years old or younger (or an adult unable to give consent), please list child's/client's first and last name

First Name

Last Name

Email

Phone

(###)

###

####

Checkbox

By clicking on "Yes, I consent to telemental health services," I certify that I have read the "Consent to Participate in a Telemedicine Appointment" form or had this form read and/or had this form explained to me, that I fully understand its contents including the risks and benefits of the procedure(s), and that I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Yes, I Consent to Telemental Health Services

Message

Please let us know if you have any concerns/special accommodations, or anything else that will help us best service you during your telemental health appointment.

Client Information & Signature Page (Required)

2024 Request for Professional Services (must read only)

Texas Notice of Privacy Procedures (must read only)

Child Self-Assessment Form (for children 17 & under)