Forms

Consents & Authorizations

General consents for all new clients to complete at intake

Referral Form

To be completed by referral source (i.e. client, parent/guardian, physician, etc.)

Student Consent

Consent form to provide treatment to students at schools

Release of Information Consent

Consent to release information from client records to a designated source

Sliding Fee Discount Application

To be completed if a discount for services is requested

Registration Form

(For Continuing Education – Suicide Assessment, Treatment, & Management – 10-28-16.) Course approved by LPC board for 6 continuing education hours to meet regulatory requirements established in 201 KAR 36:030 for LPCCs and LPCAs

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