817-756-6460 zandalpc@gmail.com

New Client Forms

Completion of  the information forms on this page before your first session is important. Let’s use your first session to focus on what brought you to counseling instead of completing forms.

Please complete this information no later than 24 hours before your first appointment.

Note:  The amount of time you will spend on these documents differs for each person but can take up to 20 minutes, depending on the information you provide. Click on the underlined titles #1 and #2 below.

1.  Intake Forms

 Informed Consent and Client Agreement
HIPAA Notice of Privacy Practices for Protected Health Information
Professional Disclosure of Qualifications
Social Media Policy

Please print, read, sign, and bring this document with you to your first session. Copies are also available in the office.

Provides general information about counseling, fees,  your rights and responsibilities, confidentiality, and other important considerations.

2.  Assessments – Follow instructions at the link. Complete and submit no later than the afternoon before your first scheduled session

3.  Intake Form – complete online below

The information below is completed online by following the prompts. Once completed select the Submit button and the information will come to me through a password protected secure email.  – Questions?  Call (817) 756-6460

What you provide will help me know more about you and what your goals are for counseling. Remember to select SUBMIT at the bottom when you finish entering your information.

Client Intake Form

  • Please choose one
  • If you are an adult, please complete the following information about education and jobs or career. You are not limited to the one line displayed below. Provide as much information at you need to.

  • Household & Family

  • Relationships & Lifestyle

  • What brings you to counseling at this time?

  • (Hobbies, exercise, interests, social activities, etc.)
  • Counseling & Treatment History

  • What are they and how often do you use? Including alcohol, marijuana, Cocaine, Designer Drugs, and others.
  • What are they? Include alcohol, marijuana, and any other mind altering substance not prescribed for medical reasons.
  • Medical Information

  • Month & Year
  • Miscellaneous

  • Referral source
  • Emergency Contact Information

  • By submitting this Intake Form, I acknowledge that I have read, understand, and agree to the HIPAA Notice of Privacy Practices for Protected Health Information.
  • This field is for validation purposes and should be left unchanged.