Forms

Please print and then complete the intake packet bring with you to your initial session.  This will allow us to complete the intake and assessment process more quickly.  We will review the forms at the first session, and I will be happy to answer any questions that you have.​

Intake Paperwork:

Child & Adolescent Clients:  PDF

Adult Clients: PDF

 

CANS Assessment: PDF

Family Therapy Clients: PDF*

* Please note that a separate Consent for Services and Receipt of Privacy Policy is required for each family member. Additional copies: Consent for Services: PDF, Receipt of Privacy Policy: PDF

 

Additional Documents Needed:

 

For divorced parents of minor clients, please bring a copy of the custody agreement to the intake session so that I may verify who may consent to treatment.

If you wish to use insurance, please bring a copy of your insurance card with you.

If there are other people that I will need to be in contact with regarding your treatment, please print and complete the Release of Information Form: PDF

Privacy Policy:

This policy is included with all intake paperwork forms. However, you may also review a copy here: HIPAA Privacy Policy

512-660-7279

13706 N Hwy 183, Ste 114

Austin, TX 78750

carolyn@therapywithcarolyn.com

  • Pinterest - Black Circle
  • b-linkedin

(C) Carolyn Mehlomakulu