Counseling Intake Forms

The necessary paperwork to get you started.

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Thank you for choosing The Relationship Center. We’re looking forward to serving you!

On this page you’ll find the forms you need to PRINT, COMPLETE, and BRING with you to your first appointment.

Much like at a physician’s office it is required by law that a professional counseling office collect essential intake forms and documentation before seeing clients.

You will need a PDF reader to view the forms. To download Adobe Reader Click Here

*Forms packets are also available for pickup at our offices (please call ahead).

*The agreements and notices maybe viewed online and do not have to be printed. Save a tree 🙂

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Springfield Office

Adult Individual

Individual Adult Counseling Intake Forms

*PRINT, FILL-OUT, SIGN, AND BRING TO THE FIRST SESSION*

Adult Intake Form

Signature Form

Financial Responsibility Agreement

If you would like us to submit insurance claims on your behalf please complete the following form. (Including Medicaid)

Insurance Claim Processing Request Form

Couples

Couples Counseling Intake Forms

*PRINT, FILL-OUT, SIGN, AND BRING TO THE FIRST SESSION*

Each person who will be present for the session will need to complete a separate Adult Intake form.

Adult Intake Form

Only 1 copy of the Signature Form and Financial Responsibility Statement are needed per couple.

Signature Form

Financial Responsibility Agreement

Each spouse should complete the online Relationship Health Score assessment separately and confidentially.

Relationship Health Score

If you would like us to submit insurance claims on your behalf please complete the following form. (Including Medicaid)

Insurance Claim Processing Request Form

Family / Child

Family Counseling Intake Forms

*PRINT, FILL-OUT, SIGN, AND BRING TO THE FIRST SESSION*

Each person who will be present for the session will need to complete a separate intake form.

Adult Intake Form

Child Intake Form (0-11)

Adolescent Intake Form (12-17)

Only 1 copy of the Signature Form and Financial Responsibility Statement are needed per family.

Signature Form

Financial Responsibility Agreement

If you would like us to submit insurance claims on your behalf please complete the following form. (Including Medicaid)

Insurance Claim Processing Request Form

Agreements & Notices

Counseling Agreement & HIPPA Privacy Policies

These forms maybe viewed online. You may print a copy for your records if you wish.

Counseling Agreement

Minors Counseling Agreement

HIPPA Disclosure

Scholarships & Payment Plans

If you’re in a desperate financial situation but earnestly want help, we will work with you to make it happen. It’s important to us that no one be unable to get help because of their financial circumstances.

Counseling Scholarships

Scholarships are Needs-Based and Sliding-Scale meaning they vary based upon your income. (application required)

Sliding Scale Counseling Scholarship Application

Counseling Payment Plans

Interest free payment plans allow you to get the help you need now and pay for it over time. (no application required, just let your counselor know)

Counseling Weekly Payment Plan Agreement