My Services
(Formerly Hoxworth Counseling Services)
For appointment, call 269-205-2402
Print & Manually Fill-in Client Forms
For your convenience and to save time before your first appointment, we have provided the required forms that you will need to complete for your first appointment. By completing the documents before you arrive, you prevent the need to arrive early for paperwork.
Directions
Download/save the form files to your device (computer, phone, tablet):
a. Right-click the desired form
b. Select 'Save link as', name the file, and then select where you want to save the file
c. Locate the downloaded form files (using PC File Explorer OR MAC Finder)
d. Double-click to open the file
e. Print the form, and then manually fill out
f. Bring the forms with you to your first appointment
ADULT Client
print & manually fill-out
Adult New Client Forms Packet - Print
Packet includes following individual forms:
1. Cover Letter
3. Authorization for Scheduling, Billing and Payment Purposes
5. PF1000 Notice of Privacy Practices
8. Notification & Coordination with
Primary Care Physician-Psychiatrist
9. Emergency Contact Authorization
10. Consent for Self-Pay Fee Sessions
Adult LENS Neurofeedback forms
Adult LENS Forms Packet - Print & manual fill in
Packet includes following 4 individual forms:
2. Intake form
MINOR (child/adolescent) Client
print & manually fill-out
Child/Adolescent New Client Forms Packet - Print
Packet includes following individual forms:
1. Cover Letter
4. Authorization for Scheduling, Billing and Payment Purposes
6. PF1000 Notice of Privacy Practices
8. Child/Adolescent Intake Form
9. Notification & Coordination with
Primary Care Physician-Psychiatrist
10. Notification & Coordination with Education Professionals
11. Emergency Contact Authorization
Minor LENS Neurofeedback forms
Minor Child/Adolescent LENS Forms Packet - Print & manual fill in
Packet includes following 4 individual forms:
1. Child/Adolescent Consent form
2. Intake form